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DISEASES  OF  THE  UEmAET  APPAEATUS. 
PHLEGM  ASIC   AFFECTIONS. 


DISEASES 


URINARY  APPARATUS 


PHLEGMASIC   AFFECTIONS 


BY 

JOHN    W.    S.    GOULEY,    M.D 

SUEGEON  TO  BELLEVUE  HOSPITAL 


NEW    TOEK 

D.    APPLETON    AND    COMPANY 

1892 


COPTEIGHT,    1892, 

By  D.  APPLETON  A?fD  COMPANY. 


PREFACE. 


The  twelve  lectures,  principallj  on  phlegmasic 
affections  of  the  urinary  a})paratus,  constituting  the 
first  part  of  a  series,  delivered  during  the  autumn  of 
1891,  and  published  in  the  New  York  Medical  Jour- 
nal, having  been  revised,  are  republished  in  this  form 
as  a  contribution  to  the  pathology  and  treatment  of 
a  class  of  diseases  the  gravity  and  frequency  of 
which  render  them  worthy  of  the  closest  study. 

The  views  expressed  in  these  conferences  are 
based  upon  long  observation  of  morbid  processes, 
frequent  comparison  of  the  effects  of  different  means 
of  cure,  and  careful  examination  of  foreign  and 
American  works  on  andrology. 

Owing  to  the  almost  incessant  advances  in  j)atho- 
histology,  bio-chemics,  and  therapeutics",  many  of  the 
conclusions  herein  stated  may  be  regarded  as  only 
provisional. 

324  Madison  Avenue,  New  York,  March,  1892. 


74^63 


CONTENTS. 


Preface  Page  v. 

SECTION   I.— GENERAL   CONSIDERATIONS. 

I. 

Introduction. — Frequency  of  Diseases  of  the  Urinary 
Apparatus. — Sketch  of  the  Composition,  Innerva- 
tion, Nutrition,  and  Function  of  the  Urinary  Ap- 
paratus. 

Advances  in  the  knowledge  of  diseases  of  the  urinary  and  genital  or- 
gans and  of  the  required  operations  for  their  relief  or  cure.  How 
this  knowledge  is  most  conveniently  acquired.  The  great  frequency 
of  diseases  of  the  urinary  and  genital  organs.  The  importance  of 
anatomical  and  physiological  investigations  in  their  study.  The 
several  regions  of  the  urethra.  The  interdependence  of  the  uri- 
nary and  genital  organs.  The  influence  of  afPections  of  the  great 
nerve  centers  upon  the  urinary  apparatus.  The  arteries,  veins,  and 
lymphatics  of  the  urinary  apparatus.  Quantity  of  urine  excreted 
each  day.  Influence  of  climate  and  season  upon  the  urinary  excre- 
tion. Effect  of  diet,  of  medicinal  agents,  and  of  the  mental  state 
upon  the  quality  and  quantity  of  the  urine      .         .         Pages  1-21 

11. 

Outline  of   the  General  Pathology  of   the  Urinary 
Apparatus. 

General  pathology  the  foundation  of  special  pathology.  The  term 
phlegmasic  affection.  The  nature  of  phlegmasia.  Emigration  of 
leucocytes.  Suppuration.  Consequences  of  phlegmasic  action. 
Stenotic,  auxetic,  echmatic,  and  ectatic  affections  often  result  from 
phlegmasia.     Lithic  affections.     Ui'oliths  and  prostatoliths.     Neo^ 


Vlll 


plasmata,  their  nature  and  classificatioii.  Adenomata  classed 
separately.  Blastomata.  Syphilis,  syphiloid,  and  tuberculosis. 
Cysts,  their  arrangement  into  epithelial,  endothelial,  degeneration, 
parasitic,  and  teratie  cysts.  Entozoic  parasites.  Spurious  worms. 
Poisons.  Traumatic  affections.  Allotrylic  affections.  Teratie 
affections.  Congenital  and  acquired  monstrosities.  Functional  dis- 
orders    Pages  22-46 

III. 

Summary  of  the  ^Etiology,  Sbmeiology,  Diagnosis, 
Prognosis,  Prophylaxis,  and  General  Therapeutics 
OF  Diseases  of  the  Urinary  Apparatus. 

Special  predispositions  to  disease  of  the  urinary  apparatus.  The  influ- 
ence of  intemperance,  of  filthy  habits,  of  excesses,  of  temperature, 
etc.  The  history  of  symptoms  such  as  pain,  tumefaction,  emacia- 
tion, changes  in  the  mode  of  urination,  is  seldom  accurately  de- 
tailed by  the  patient  to  the  physician,  who  is  forced  to  resort  to 
tedious  cross-examination.  Disordered  urination  covers  a  wide 
field  of  inquiry.  Frequent,  irrepressible,  difficult,  painful,  involun- 
tary, or  impossible  uriuntion.  The  jet  of  urine  may  be  irregular, 
small,  feeble,  interrupted,  or  absent.  Inquiry  as  to  the  amount  of 
urine  passed  each  day.  The  physical  characters  and  chemical 
properties  of  abnormal  urine.  Thudicum's  table  illustrative  of  the 
tints  of  the  urine.  Substances  which  exist  in  normal  urine,  but 
constitute  abnormities  when  in  excess.  Substances  which  do  not 
exist  in  normal  urine,  and  the  presence  of  which  'constitutes  abnor- 
mities. Diagnosis.  Prognosis.  Prophylaxis.  General  thera- 
peusis Pages  41 -IS 

SECTION   II.— SPECIAL   CONSIDERATIONS. 

IV. 

Interstitial  Nephritis,  Pyelonephritis,  and  Perine- 
phritis ;  their  Nature,  Symptoms,  Progress,  Diag- 
nosis, AND  Treatment. 

Descending  and  ascending  nephritis.  Descending  nephritis  secondary 
to  disease  of  some  organ  foreign  to  the  urinary  apparatus.     Ascend- 


IX 


ing  nephritis  secondary  to  disease  of  the  lower  urinary  organs. 
Amicrobic  and  microbic  nephritis.  Parenchymatous  and  intersti- 
tial nephritis.  Contracted  kidneys.  Occasional  fatal  results  of 
ether  inhalation.  Symptoms  of  acute  interstitial  nephritis,  whether 
due  to  catheterism  or  other  operation.  Urethral  or  urinary  fever. 
Diagnosis,  prognosis,  and  anatomical  characters  of  acute  interstitial 
nephritis.  Treatment  of  acute  interstitial  nephritis.  Ascending 
microbic  pyelonephritis  is  generally  the  outcome  of  neglected  ure- 
thral or  prostatic  obstruction,  vesical  stones,  tumors,  tuberculosis, 
entozoa,  foreign  bodies,  injuries  or  diseases  of  the  spinal  cord 
leading  to  paraplegia,  and  the  use  of  unclean  instruments.  The 
symptoms,  diagnosis,  prognosis,  gross  necropsic  appearances,  and 
treatment  of  microbic  pyelonephritis.  Primary  perinephritis,  due 
to  injuries  such  as  strains,  contusions,  or  wounds  independent  of 
any  kidney  lesion,  or  to  dyscrasic  influences  such  as  give  rise  to 
rheumatism,  etc.  Secondary  perinephritis,  due  to  injuries  and 
other  affections  of  the  kidney  such  as  nephric  abscess,  pyonephro- 
sis, pyelonephritis,  calculous  concretions,  parasites,  tuberculosis, 
malignant  disease,  and  to  caries  of  the  vertebrae,  ulceration  of  the 
intestines,  or  to  disease  of  other  organs.  Symptoms,  progress, 
diagnosis,  and  treatment  of  perinephritis      .         .         Pages  '74-101 


Cystitis  ;  its  Causes,  Symptoms,  Progress,  Anatomical 
Characters,  Diagnosis,  and  Prognosis. 

Cystitis  arising  from  deviations  in  quantity  or  quality  of  the  urinary 
secretion,  due  to  disturbed  innervation,  structural  disease  of  the 
kidney,  paludal  fevers,  injury  of  an  extensive  cutaneous  surface 
such  as  occurs  from  laceration,  burns  or  scalds,  exposure  to  humid 
cold,  etc.  Effect  of  persistent  hyperlithuria,  pyuria,  glycosuria,  of 
the  absorption  of  cantharidine,  turpentine,  or  alcohol,  and  of  pro- 
longed ansesthesia,  upon  the  vesical  mucous  membrane.  Cystitis 
arising  from  the  extension  of  phlegmasic  action  of  neighboi'ing  or- 
gans, such  as  urethritis,  etc.  Cystitis  arising  from  injuries  of  the 
bladder  and  from  other  local  irritants,  such  as  violent  catheterism, 
contusions  or  wounds  of  the  bladder,  calculi,  foreign  bodies,  en- 
tozoa, new  growths,  tuberculosis,  etc.     Cystitis  arising  from  stag- 


nation  and  fermentation  of  urine  due  to  obstructed  urination,  as 
urethral  stenosis,  prostatic  obstruction,  etc.  Symptoms  of  acute 
cystitis.  Unduly  frequent  and  painful  urination.  Spasm  of  the 
bladder.  Irrepressible  urination.  Haematuria.  ,  Pyuria,  etc.  Symp- 
toms of  chronic  cystitis  due  to  urethral  or  prostatic  obstruction. 
Frequent,  difficult,  and  painful  urination.  Alkaline  and  purulent 
urine  passed  in  a  small  stream  or  in  drops,  etc.  Progress  of  cys- 
titis. Normal  appearances  of  the  bladder.  Anatomical  charac- 
ters of  cystitis.  Catarrh  of  the  bladder.  Slimy  urine.  Diagnosis 
and  prognosis  of  cystitis.     Conclusions      .         .         Pages  102-131 

vr. 

Cystitis  ;   its  Treatment. 

General  and  special  indications.  Constitutional  and  local  treatment. 
Management  of  cystitis  with  vesical  contracture.  Gradual  hydraulic 
dilatation  of  the  contractured  bladder.  Nitrate  of  silver  in  cystitis 
by  instillations  and  by  injections.  Action  of  nitrate-of-silver  solu. 
tions  upon  mucous  membranes.  Corrosive  chloride  of  mercury  in 
cystitis.  Cystotomy,  infrapubic  and  suprapubic.  Treatment  of  acute 
trachelocystitis.  Management  of  cystitis  due  to  urethral  stricture. 
The  cystitis  of  elderly  men  affected  with  prostatic  enlargement 
Vesical  haemorrhage.  Treatment  of  the  cystitis  due  to  disease  or 
injury  of  the  great  nerve  centers        .         .         .         Pages  132-158 


YII. 

Prostatitis  and  Bulbo-urethral   Adenitis. 

Acute  prostatitis,  its  nature,  causes,  symptoms,  progress,  diagnosis,  and 
treatment.  Prostatitis  from  exposure  to  cold  and  dampness. 
Chronic  prostatitis,  its  anatomical  characters.  Prostatic  concre- 
tions. Diagnosis  and  treatment  of  chronic  prostatitis.  Injections 
and  instillations  of  nitrate-of-silver  solutions.  General  medication. 
The  bulbo-urethral  glands,  some  points  in  their  special  anatomy  and 
physiology.  Bulbo-urethral  adenitis,  its  symptoms,  progress,  diag 
nosis,  and  treatment Pages  159-188 


XI 

VIII. 

Urethritis  ;  its  Nature,  Causes,  and  Diagnosis. 

The  various  names  given  to  this  phlegmasia.  Discussions  respecting 
the  nature  of  urethritis.  The  identists  and  non-identists.  Causes 
of  urethritis.  Infecting  and  non-infecting  urethritis.  Immediate 
and  mediate  contagion.  Nature  of  the  contagium  of  urethritis.  The 
"  gonococcus."  Seventy-five  per  cent,  of  all  cases  of  urethritis  non- 
contagious. Causes  of  non-contagious  urethritis — sexual  excess, 
masturbation,  alcoholism,  mechanical  irritants.  Urethritis  in  elderly 
men.  Diagnosis.  Benign,  subacute,  acute,  and  superacute  ure 
thritis,  the  distinctive  characters  of  each  type     .        Pages  189-223 

IX. 

Treatment  of  the  Acute  Types  of  Urethritis. 

Urethritis  being  a  stricture  171  posse,  the  treatment  should  be  directed 
to  the  prevention  of  stricture.  Objections  to  the  so-callecj  abortive 
treatment  with  strong  solutions  of  nitrate  of  silver.  The  use  and 
abuse  of  balsainics  and  of  astringent  injections.  Hygienic  precau- 
tions. Rational  treatment  of  the  first,  second,  third,  and  fourth 
stages  of  acute  urethritis.  Management  of  supei'acute  urethritis. 
Urethral  injections  applicable  only  during  the  first  and  fourth  stages 
of  acute  and  superacute  urethritis.     Conclusions  .     Pages  224-23*7 

X. 

Accidents,  Complications,  and    Consequences    of    the 
Acute  Types  of  Urethritis. 

Urethral  hcemorrhage.  Breaking  of  the  "  chordee."  Virulent  con- 
junctivitis, its  management.  Balanitis,  posthitis,  balano-posthitis, 
phimosis,  and  paraphimosis,  their  treatment.  Lymphangeitis,  sub- 
acute, acute,  and  superacute.  Inguinal  adenitis.  Peri-urethritis, 
often  caused  by  superacute  urethritis,  its  treatment.  Urethral 
cryptitis.  Bulbo-urethral  adenitis.  Prostatitis.  Orchitis.  Epidid}'- 
mitis,  its  frequency.  Didymitis,  of  rare  occurrence  as  compared  to 
epididymitis.  Phlegmasia  of  the  spermatic  canal  and  cord.  Treat 
ment  of  epididymitis  and  didymitis    .         .         .         Pages  238-262 


Xll 


XT. 

Consequences  of  Acute  Urethkitis  continued  ;  Gone- 
cystitis,  Tkachelocystitis,  Pyelitis,  Septicaemia, 
Pyosapr.emia,   and  Rheumatism. 

Sketch  of  the  special  anatomy,  histology,  and  physiology  of  the  seminal 
vesicles.  Acute  gonecystitis,  its  frequency,  causes,  and  symptoms. 
Sometimes  mistaken  for  acute  prostatitis,  with  which  it  is  occasion- 
ally associated.  Antiphlogistic  treatment  during  the  stage  of  in- 
crease. Later,  incision  in  case  of  abscess.  Chronic  gonecystitis, 
its  causes,  symptoms,  diagnosis,  and  treatment.  Ectasia  of  the 
vesicles  and  spermatic  canals.  Shriveling  of  the  vesicles  in  elderly 
men  suffering  from  prostatic  obstruction.  Trachelocystitis.  Pye- 
litis and  nephritis.  Septicemia.  Pyosapraemia.  Rheumatism,  ex- 
cited, invulnerable  subjects,  by  genital  phlegmasia  .  Pages  263-289 

XII. 

Chronic    Urethritis  ;    its    Nature,    Causes,    Physical 
Characters,  Diagnosis,  and  Treatment. 

The  difference  between  chronic  urethritis  and  blennorrhoea.  The  na- 
ture of  chronic  urethral  discharges.  Moral  condition  of  sufferers 
from  chronic  urethral  discharges.  Chronic  urethritis  is  non-con- 
tagious. The  chief  causes  of  the  persistence  of  urethritis  are  dis- 
regard of  hygienic  precautions  during  acute  urethritis,  inappropriate 
treatment  of  the  acute  types  of  urethritis,  vulnerability  of  the  sub- 
ject, continued  local  irritation  of  the  urethra,  and  excessive  general 
and  local  treatment  of  the  acute  types.  Physical  characters  of 
chronic  urethritis.  Diagnosis  of  chronic  urethritis.  Moral,  general, 
and  local  treatment Pages  290-808 

ADDENDUM. 

Retention  of  Urine  from  Prostatic  Obstruction  in 
Elderly  Men  ;  its  Nature,  Diagnosis,  and  Man- 
agement. 

Causes  of  impediment  to  urination  in  elderly  men.  The  several  forms 
of  unequal  enlargement  of  the  prostate.     The  different  alterations 


XIU 


of  structure  in  prostatic  enlargement.  The  first  effect  of  urethra]  or 
urethro-vesical  obstruction  is  stagnation  of  urine  in  the  bladders 
The  early  manifestations  of  prostatic  enlargement  do  not  alway 
cause  anxiety  and  are  often  overlooked.  Diagnosis  of  retention  of 
urine  from  prostatic  enlargement.  Mercier's  rectangular  sound. 
The  cysto-pylometer.  The  mechanism  of  acute  retention  of  urine. 
The  management  of  acute  retention  of  urine,  and  its  after-treat- 
ment. Chronic  retention  of  urine.  Catheters.  One  catheter  can 
not  answer  in  all  cases.  The  size  of  catheters.  The  invaginated 
catheter  of  Mercier.  Puncture  of  the  bladder.  The  general  treat- 
ment in  cases  of  stagnation  of  urine  .         .         .         Pages  309-333 


T 


DISEASES  OF  THE  UlilNAEY  APPARATUS. 

PART   L— PHLEGMASIC  AFFECTIONS. 


SECTioif  I.— GENERAL    CONSIDERATIONS. 

I. 

Introduction.  —  Frequency  of  Diseases  of  the  Urinary 
Apparatus. — Sketch  of  the  Composition,  Innervation, 
Nutrition,  and  Function  of  the  Urinary  Apparatus. 

The  present  knowledge  of  affections  of  tlie  urinary  and 
genital  apparatus,  and  of  means  for  their  relief,  is  the  ac- 
cretion of  the  experiences  of  many  thousand  years.  All 
nations  and  generations  have  contributed  their  quota  in  the 
slow  but  steady  advances  that  have  been  made.  It  requires 
no  great  stretch  of  the  imagination  to  picture  a  young 
savage,  far  back  in  the  mists  of  time,  harassed  by  frequent 
and  difficult  urination  owing  to  a  narrow  stenosis  of  the 
preputial  orifice,  conceiving  the  idea  of  sharpening  a  stone 
and  with  it  excising  the  end  of  the  prepuce,  and  thus  re- 
moving the  annoying  obstruction.  This  prompt  relief  in- 
ducing him  to  try  the  experiment  upon  others,  he  becomes 
the  posthectomist  of  his  tribe.  An  aged  savage,  too,  may 
be  pictured  in  the  throes  of  retention  of  urine  searching- 
means  of  relief,  and  finding  a  smooth,  hollow  reed,  rounds 
its  extremity,  spits  upon  it,  performs  rectilinear  catheterism. 


and  relieves  his  distended  bladder.  He  then  exhibits  with 
joy  the  improvised  instrument  that  has  saved  him,  and  per- 
haps also  an  improvement  thereon,  and  his  elderly  neigh- 
bors, similarly  affected,  take  advantage  of  the  discovery. 

The  following  statement  is  made  to  show  that  auto- 
catheterism  with  a  reed  is  not  purely  imaginary,  but  has 
been  successfully  practiced  for  the  relief  of  retention  of 
urine  :  A  Tasmanian,  under  the  care  of  the  writer  for 
urethral  stricture,  said  that  while  in  his  country  far  away 
"  in  the  bush  "  he  was  seized  with  retention  of  urine,  and 
suifered  so  much  in  consequence  that  he  looked  for  and 
found  a  reed  of  suitable  size,  which,  after  a  little  rude 
preparation,  he  moistened  with  saliva  and  introduced  into 
his  urethra,  and  thus  relieved  his  distended  bladder.  The 
writer  is  in  possession  of  two  small  straight  rods  made  of 
bamboo,  smoothed,  rDunded,  and  charred  at  both  extremi- 
ties. These  rudely  improvised  instruments  had  been  used 
for  several  months  by  another  patient,  a  rustic,  almost  a 
savage,  for  the  relief  of  frequent  attacks  of  retention  of 
urine  due  to  urethral  stricture.  He  said  that  he  had  pre- 
pared them  himself,  and  that  whenever  unable  to  urinate 
he  introduced  the  smaller  and  then  sometimes  the  larger, 
immediately  on  whose  withdrawal  the  urine  flowed  freely. 

The  operation  of  posthectomy  appears  to  have  been 
commonly  practiced  by  several  ancient  Eastern  nations, 
notably  the  Egyptians,  who  were  in  the  habit  of  perform- 
ing the  operation  for  the  cure  as  well  as  the  prevention  of 
disease  thousands  of  years  ago. 

Another  operation,  orchidectomy,  whose   invention  is 


ascribed  to  Semiramis,  the  Assyrian  queen,  may  be  traced 
to  savage  life,  and  even  the  savages  may  have  learned  it 
from  the  lower  animals,  for  there  are  not  few  of  the  smaller 
polygamous  beasts  that  destroy  the  testicles  of  the  super- 
fluous yoimg  males.  So  it  would  seem  that  eunuchism  is 
not  confined  to  man.  Many  therapic  devices,  too  well 
known  to  require  present  commentary,  have  been  learned 
from  the  lower  animals. 

It  is  recorded  that  the  cannibal  Caribs  discovered  by 
Columbus  were  in  the  habit  of  emasculating  their  young 
prisoners  to  be  fattened  and  then  devoured. 

Lumbar  incision  to  let  out  pus  from  nephric  or  peri- 
nephric abscess  date's  back  more  than  two  thousand  years. 

The  time  when  was  introduced  the  cutting  open  of  the 
bladder  for  the  extraction  of  a  stone  is  unknown.  That  it 
was  habitually  performed  during  the  life  of  Hippocrates  is 
evidenced  in  a  clause  of  the  oath  which  this  great  master 
caiised  his  disciples  to  take,  forbidding  them  to  practice  the 
operation,  and  relegating  it  to  specialists.     • 

Lithoclastic  cystotomy  is  attributed  to  xlmmonius,  of 
Alexandria,  who  lived  two  hundred  and  seventy-six  years 
before  the  Christian  era  and  was  surnamed  Lithotomos? 
stone-cutter,  from  which  arose  the  term  lithotomy,  now 
having  the  arbitrary  signification  of  cutting  for  the  stone. 

Celsus  first  described  the  manner  of  using  catheters  for 
the  relief  of  retention  of  urine,  and  the  general  directions 
he  gave  are  followed  to  this  day.  Of  late  years  bronze 
catheters  have  been  unearthed  from  the  ruins  of  Pompeii. 
This  discovery,  together  with  the  account  of  them  given  by 


Celsus,  shows  that  these  instruments  were  in  common  use 
before  the  Christian  era. 

It  was  Celsus,  too,  who  gave  the  first  description  of 
lithotomy  as  performed  before  and  during  his  time,  and  the 
operation  has  ever  since  borne  his  name — the  Celsian 
method. 

The  greatest  advances  made  in  andrology  are  due  to  the 
endeavors  to  improve  lithotomy,  and  later  to  discover  other 
means  of  relieving  sufferers  from  calculous  affections. 
These  improvements  were  begun  in  Italy,  but  the  names  of 
those  surgeons  who  made  them  have  long  since  been  for- 
gotten, and  no  writing  has  been  found  anterior  to  Mariano 
Santo  (1525),  who  seems  to  have  been  the  mouthpiece  of 
his  master,  G-iovanni  di  Komani.  The  method  described  is 
known  as  the  Marian.  The  proprietary  operation  then 
passed  into  the  hands  of  the  Colots  of  France,  remained  a 
family  secret  for  more  than  a  century,  and  was  not  divulged 
until  a  surgeon,  concealed  in  an  upper  room,  surprised  them 
in  the  act  of  operating,  by  looking  through  a  hole  in  the 
floor.  Franco  had,  however,  already  (1561)  devised  and 
published  two  methods  of  his  own,  one  of  which  was  the 
suprapubic. 

From  the  time  of  the  Colots  lithotomy  became  a  com- 
mon operation  in  Europe ;  it  became  still  more  common  on 
the  advent  of  Frere  Jacques,  who  is  said  to  have  operated 
more  than  five  thousand  times.  The  frequent  use  of  the 
sound  in  searching  for  vesical  stones  led  to  the  better  study 
of  urethral  obstructions  and  finally  to  the  specialization  of 
urethral  strictures. 


Still  fiirtlaer  advances  were  made  in  the  eighteentli 
century,  but  a  gigantic  step  was  taten  almost  from  tlie 
moment  of  the  introduction  of  lithotripsy  (1824),  which 
required  the  most  careful  study  of  the  urethra  and  of  those 
lesions  of  the  upper  urinary  organs  that  so  often  contra- 
indicate  surgical  interference.  T\"ith  lithotripsy  and  the 
advances  it  suggested  are  connected  the  names  of  the  most 
diligent  laborers  in  surgery  of  Europe  and  America,  De- 
spite this  great  progress,  there  remains  much  to  be  done 
toward  improving  the  present  knowledge  of  the  pathology 
and  therapy  of  these  affections  by  succeeding  generations 
of  physicians,  and  the  future  advances  will  be  proportion- 
ate to  improvements  in  methods  of  study. 

The  main  object  of  the  proposed  conferences  is  to  out- 
line what  is  conceived  to  be  a  direct  and  convenient  method 
of  studying  the  diseases  that  affect  the  urinary  apparatus, 
and  incidentally  to  point  out  the  degree  of  responsibility 
assumed  by  the  physician  when  he  undertakes  the  manage- 
ment of  any  disease  of  this  apparatus,  and  also  his  obliga- 
tion to  acquire  an  adequate  knowledge  of  the  normal  and 
morbid  anatomy  and  therapeutics  of  the  urinary  organs. 
The  material  requisite  to  this  adequate  knowledge  is  gath- 
ered from  the  study  of  medical  and  surgical  treatises,  from 
the  observation  of  cases  of  disease,  and  from  written  and 
oral  conferences,  the  object  of  such  conferences  being 
ordinarily  to  convey  information  in  part  gleaned  from 
trustworthy  sources,  notably  those  that  are  not  of  easy 
access  to  the  majority  of  readers,  and  in  part  derived  from 
close  observation  and  extended  experience.     In  other  words, 


6 


these  conferences,  to  be  time  and  labor  saving  to  the  list- 
ener, should  consist  mainly  of  conclusions  arrived  at  by 
the  writer  or  speaker  from  the  analysis  and  synthesis  of 
his  experience  as  well  as  the  recorded  experiences  of  others. 
To  carry  out  the  legitimate  purposes  of  these  confer- 
ences will  be  to  present,  in  the  form  of  condensed  disquisi- 
tions, the  results  of  a  careful  examination  of  questions  relat- 
ing to  the  pathology,  aetiology,  symptomatology,  diagnosis, 
and  treatment  of  abnormal  conditions  of  the  male  urinary 
apparatus  that  come  within  the  province  of  surgeons. 

Frequexct  of  Diseases  of  the  TTrixart  Apparatus. 
— It  may  be  safely  asserted  that  two  thirds  of  the  male 
iuliabitants  of  large  cities,  from  early  infancy  to  extreme 
old  age,  suffer  from  some  affection  of  the  urinary  or  of  the 
genital  apparatus ;  that  half  of  the  adult  males  have  had 
urethritis ;  and  that  at  least  half  of  all  men  above  the  age 
of  fifty  suffer  from  some  disease  of  the  bladder  or  prostate. 
Hence  the  importance  of  their  special  study. 

The  urinary  and  genital  organs  are  primarily  or  sec- 
ondarily affected  by  disease  or  by  injury — that  is  to  say, 
a  disease  may  begin  in  one  of  the  organs,  and  another  or- 
gan may  suffer  secondarily  from  this  disease ;  and  if  an 
organ  be  injured,  another  organ  may,  in  consequence,  be- 
come involved  in  disease.  Again,  some  disease  originating 
in  a  distant  part  of  the  body  may  disturb  the  function  of 
the  apparatus,  and  even  cause  disease  of  several  of  the  uri- 
nary organs.  For  example,  any  disease  or  injury  which 
seriously  impedes  the  outflow  of  the  urine  reacts  upon  the 


bladder,  ureters,  and  kidneys.  Certain  abnormal  states  of 
tbe  digestive  apparatus  are  known  to  give  rise  to  hyper- 
litburia  and  glycosuria,  the  latter  being  sometimes  caused 
by  grave  cerebral  disease.  Excessive  litburia  causes  irrita- 
tion and  even  inflammation  of  the  ureters,  bladder,  and 
urethra.  Long-continued  polyuria  often  causes  renal  and 
vesical  disease. 

Many  of  the  diseases  of  the  urinary  organs  are  cura- 
ble, and  the  most  hopeless  are  amenable  to  palliative  treat- 
ment, designed  to  relieve  pain  and  prolong  life. 

Inasmuch  as  a  correct  conception  of  disease  can  not  be 
formed  without  previous  study  of  the  nature  and  uses  of 
the  organs  of  the  human  body — disease  being  a  departure 
from  the  normal  state  of  any  of  these  organs — it  is  wise  to 
bestow  more  than  ordinary  attention  upon  the  anatomy  and 
physiology  of  the  urinary  and  genital  apparatus,  and  thus 
to  take  a  forward  step  in  the  direction  of  exactness  in  diag- 
nosis and  success  in  treatment.  Only  a  part  of  the  required 
knowledge  can  be  obtained  from  the  perusal  of  works  on 
anatomy  and  physiology  and  of  treatises  on  the  normal  and 
diseased  urinaiy  organs;  the  remainder  is  to  be  gained  sole- 
ly from  the  cadaver,  used  with  two  objects  :  first,  to  learn 
practically  the  descriptive,  relative,  and  morbid  anatomy  of 
these  organs;  and  second,  to  rehearse  all  needed  operations, 
even  simple  catheterism. 

Since  a  dissertation  on  special  anatomy  and  physiology 
would  here  be  out  of  place,  a  simple  sketch  will  be  given  of 
the  composition,  innervation,  nutrition,  and  function  of  the 
urinary  apparatus  as  an  introduction  to  the  description  of 


diseases  whicli  are  to  be  studied,  referring  tlie  student,  for 
further  information,  not  only  to  works  on  anatomy  and 
physiology,  but  to  the  anatomical  laboratory. 

Composition  of  the  Urinary  Apparatus. — The  uri- 
nary apparatus  consists  of  the  kidneys,  the  ureters,  tlie  blad- 
.  der,  the  prostate,  and  the  urethra.  The  kidneys  excrete  the 
urine  which,  after  a  short  detention  in  the  renal  pelves,  is 
conveyed  through  the  ureters — whose  caliber,  narrow  at  each 
extremity  of  the  duct,  averages  three  sixteenths  of  an  inch, 
and  whose  length  ranges  from  twelve  to  fifteen  inches — to 
the  bladder,  whence,  after  longer  detention,  it  is  finally  ex- 
pelled through  the  urethra.  Some  of  the  organs  of  the 
urinary  apparatus  are  common  to  the  genital  apparatus — 
namely,  the  prostate  and  urethra — and  all  of  them,  except 
the  kidneys,  are  in  close  relation  with  most  of  the  genita^ 
organs. 

The  genital  apparatus  consists  of  the  testicles,  the  sper- 
matic canals,  the  seminal  vesicles,  the  prostate,  the  bulbo- 
urethral glands,  the  urethra,  and  the  penis. 

Of  the  organs  of  the  urinary  and  genital  apparatus, 
the  kidneys,  ureters,  bladder,  prostate,  and  seminal  vesicles 
are  intra-abdominal ;  the  urethra  and  spermatic  canals  are 
partly  within  and  partly  without ;  while  the  penis  and  tes- 
ticles are  external. 

Inasmuch  as  many  of  the  diseases  of  the  upper  urinaiy 
organs  are  consequent  upon  urethral  affections,  and  inas- 
much as  the  diseased  urethra  in  its  divers  parts  requires 
modifications  in  treatment,  it  is  necessary,  for  practical  pur- 


9 


poses,  that  these  several  parts  be  specialized.  A  simple 
division  into  the  six  following  regions  seems  sufficient  for 
this  end  :  1.  The  prostatic  region:  that  part  of  the  canal 
which  traverses  the  prostate  in  its  longitudinal  axis,  from 
the  urethro-vesical  orifice  to  the  prostatic  apex.  2.  The 
membranous  region :  that  part  of  the  canal  which  is  between 
the  two  layers  of  the  triangular  ligament,  from  the  apex  of 
the  prostate  to  the  urethral  bulb.  3.  The  perineal  region  : 
that  part  of  the  canal  which  is  in  the  perinaeum,  from  the 
anterior  face  of  the  triangular  ligament  to  the  posterior  limit 
of  the  scrotum.  4.  The  scrotal  region :  that  part  of  the  canal 
which  is  covered  by  the  scrotum.  5.  The  phallic  region : 
that  part  of  the  canal  which  begins  at  the  peno-scrotal  junc- 
tion and  ends  at  the  base  of  the  glans  penis.  6.  The  ba- 
lanic  region :  that  part  of  the  canal  which  extends  from  the 
base  of  the  glans  penis  to  the  external  urethral  orifice. 

These  organs  are  so  intimately  associated  and  so  inter- 
dependent that  disorders  of  any  of  the  urinary  organs  often 
cause  some  derangement  of  the  others  and  react  upon  the 
genital  organs,  and  sometimes  also  upon  the  whole  organ- 
ism. This  happens  partly  through  the  vascular  system, 
partly  through  the  medium  of  the  nervous  system. 

Innervation  of  the  Urinary  Apparatus. — The  uri- 
nary, like  the  other  organs  of  the  human  body,  derive  their 
innervation  from  both  the  sympathetic  and  cerebro-spinal 
nervous  systems — the  one  presiding  over  nutrition  and  ex- 
cretion, the  other  over  motion,  sensation,  and  intellection  ; 
the  two  freely  intercommunicating  by  many  branches,  and 


10 


the  sympathetic  following  the  cerebro-spinal  system  through- 
out the  body  and  supplying  the  muscular  fibers  and  the 
blood-vessels  to  their  utmost  ramifications.  The  double 
prevertebral  chain  of  sympathetic  ganglia,  besides  sending 
communicating  filaments  to  the  nerves  of  the  cerebro-spinal 
system,  forms  separate  ganglia  in  the  thoracic  and  abdomi- 
nal cavities,  such  as  the  semilunar,  which  give  off  the  solar 
plexus  and  superior  and  inferior  hypogastric  plexuses  for 
the  supply  of  the  abdominal  and  pelvic  viscera.  From  the 
sacral  plexus  of  spinal  nerves  arise  the  great  sciatic  nerve, 
and  the  internal  pudic,  which  sends  a  branch  to  the  penis, 
one  to  the  bulbo-cavernosus  muscle,  and  one  cutaneous 
branch  to  the  scrotum  and  to  the  lower  surface  of  the  penis. 
These  systems  of  nerves  are  conducting  media  for  the  trans- 
mission of  impressions  to  the  great  centers. 

When,  from  disease  or  injury,  either  nervous  system  is 
impaired,  the  function  of  the  urinary  apparatus  is  disturbed 
in  a  degree  proportionate  to  the  lesion  of  the  nerve  center. 
For  example,  in  a  case  of  compression  of  the  brain  where 
sensation  and  volition  are  null,  the  bladder  becomes  gradu- 
ally distended  with  urine ;  the  patient  receives  no  warning 
of  the  fact,  as  he  should  through  his  sensory  nerves  if  their 
action  had  not  been  interrupted  ;  he  does  not  experience 
the  need  to  urinate  and  can  make  no  complaint  of  pain  and 
cry  out  for  relief — so  the  urine  continues  to  accumulate  to 
the  point  of  greatly  overdistending  the  bladder.  If  he  re- 
gain consciousness,  he  may  soon  have  an  urgent  desire  to 
urinate  without,  however,  the  ability  to  do  so,  and  this  may 
continue  for  days  or  weeks  after  the  bladder  has  been  re- 


11 


lieved  artificially.  This  disability  is  the  result  of  direct  in- 
jury to  the  bladder — i.  e.,  the  mechanical  distention  to  which 
it  has  been  subjected  owing  to  accumulation  from  a  cessa- 
tion of  the  desire  to  urinate.  In  such  a  case  the  vesical 
nerves  have  doubtless  suffered  from  overstretching,  but  the 
muscular  coat  of  the  bladder  has  received,  from  this  same 
cause,  the  greater  injury,  hence  the  length  of  time  required 
for  the  restoration  of  normal  urination.  In  ordinary  com- 
plete paralysis  there  should  be  incontinence  and  not  reten- 
tion of  urine — that  is  to  say,  the  urine  should  escape  from 
the  bladder  as  fast  as  it  oozes  from  the  ureters. 

A  proper  appreciation  of  the  intimate  relations  that  the 
urinary  organs  bear  one  to  another  through  their  supply  of 
nerves  enables  the  student,  in  a  measure,  to  explain  the 
phenomena  to  which  their  derangement  may  lead.  For  in- 
stance, retention  of  urine  in  the  bladder  often  causes  severe 
griping  pain  in  the  intestines  and  sometimes  obstinate 
vomiting.  Nephritic  colic,  stone  in  the  bladder,  and  cys- 
titis give  rise  to  similar  symptoms.  The  introduction  of  a 
catheter  into  the  urethra  is  occasionally  followed  by  alarm- 
ing symptoms  which  appear  to  be  due  to  shock  propagated 
through  the  medium  of  the  sympathetic  nervous  system 
whose  ramifications  permeate  the  whole  body.  Another 
phenomenon  well  worthy  of  notice  is  an  obstinate  spas- 
modic cough  during  the  process  of  catheterism  in  certain 
neurotic  subjects,  which  cough  ceases  as  soon  as  the  cathe- 
ter is  withdrawn.  Even  the  act  of  normal  urination  is  at 
times  accompanied  by  a  shiver  which,  in  some  cases,  is 
greatly  exaggerated. 


12 


Bearing-  in  mind  tliat  tlie  nerves  of  motion  and  sensa- 
tion derived  from  the  cerebro-spinal  system  also  supply 
the  urinary  organs,  it  is  easy  to  account  for  certain  urinary 
neuroses  wliich  sometimes  occur  in  parts  of  the  body  dis- 
tant from  these  organs,  such  as  the  feet,  legs,  anterior  crural, 
sciatic,  and  lumbar  regions.  These  neuroses  have  long  ago 
been  recognized  by  surgeons  as  symptoms  of  disease  of  the 
urinary  organs. 

Nutrition  of  the  Urinary  Apparatus  :  Vascular  Sys- 
tem.— Certain  arteries  carry  red  blood  to  the  urinary  organs 
for  their  nutrition,  as  well  as  for  the  supply  of  materials  to 
be  eliminated ;  certain  veins  carry  away  the  blood  when  it 
has  become  charged  with  effete  matter;  and  certain  lym- 
phatic, absorbent  vessels  collect  from  the  mucous  surface  of 
the  alimentary  canal  nutrient  substances,  and  from  the  tissues 
of  the  organs  gather  both  effete  and  morbid  materials  and 
carry  them  away,  some  in  solution,  others  in  suspension,  in 
a  milky  fluid,  called  lymph  or  white  blood,  which  is  poured 
into  the  venous  torrent. 

The  arteries  that  supply  the  urinary  and  genital  organs 
are  derived  from  the  abdominal  aorta,  as  the  renal  and  sper- 
matic ;  and  from  the  internal  iliac,  as  the  umbilical,  inferior 
vesical,  middle  hisemorrhoidal,  obturator,  and  internal  pudic. 

The  renal  or  emulgent  arteries,  nearly  as  large  as  the 
coeliac  axis,  are  given  off  at  right  angles  by  the  abdominal 
aorta  at  a  short  distance  below  the  superior  mesenteric  ar- 
tery, and  are  especially  remarkable  for  their  large  caliber 
relatively  to  the  size  of  the  kidneys  which  they  supply. 


13 


This  anatomical  disproportion  is  in  obedience  to  a  physio- 
logical law  which  requires  the  supply  of  blood  to  be  ade- 
quate to  the  excretory  activity  of  the  organ.  The  kidneys 
excrete  from  two  and  a  half  to  three  pints  of  urine  in  every 
twenty-four  hours  ;  hence  the  very  large  caliber  of  their 
arteries.  The  renal  arteries  send  but  few  and  small  col- 
lateral branches  to  the  suprarenal  capsules  and  to  the  cellulo- 
adipose  capsules.  The  right  renal  artery  is  somewhat  longer 
than  the  left,  and  arises  a  little  lower  down.  At  the  hilum 
of  each  kidney  the  artery  divides  into  several  branches,  some 
of  which  enter  the  organ  between  the  basin  and  renal  vein, 
others  behind  the  basin,  and,  after  further  subdivision,  pene- 
trate the  substance  of  the  kidney  between  the  cones  of  Mal- 
pighi,  and  go  to  form  the  capillary  system  of  the  cortical 
portion. 

The  unobliterated  portions  of  the  umbilical  arteries  give 
off  superior,  middle,  and  inferior  vesical  branches ;  other 
inferior  vesical  branches  arise  from  the  internal  iliacs,  and 
these  branches  are  distributed  to  the  lower  fundus  of  the 
bladder,  to  the  prostate,  to  the  seminal  vesicles,  and  to  the 
spermatic  canals.  The  middle  hsemorrhoidal  vessels  send 
branches  to  the  spermatic  canals,  the  seminal  vesicles,  and 
to  the  posterior  part  of  the  bladder.  The  obturator  arteries 
send  a  few  lateral  branches  to  the  bladder.  The  internal 
pudic  arteries,  which  are  the  terminal  branches  of  the  inter- 
nal iliacs,  give  off  the  anterior  vesical,  and  divide  into  the 
cavernous  and  the  dorsal  arteries  of  the  penis,  and,  finally, 
into  the  arteries  of  the  urethral  bulb  and  the  superficial  peri- 
neal arteries. 


u 

The  veins  of  tlie  urinary  and  genital  organs,  "nith  the 
excej)tion  of  the  renal  veins,  are  supplied  with  valres. 
The  caliber  of  all  these  veins  is  much  greater  than  that  of 
the  corresponding  arteries,  but  the  "walls  of  the  veins  are 
much  thinner  than  those  of  the  arteries. 

The  renal  or  emulgent  veins  are  much  larger  than  their 
accompanying  arteries.  The  left  vein  is  a  little  larger, 
longer,  and  more  horizontal  than  the  right,  and  receives 
the  left  spermatic  vein.  Each  renal  vein  originates  in 
the  cortical  substance  of  the  kidney  in  a  great  number  of 
venules.  These  unite  to  form  larger  branches,  which  con- 
verge at  the  hilum  into  a  single  trunk,  destined  to  carry  the 
blood  to  the  inferior  vena  cava.  The  other  veins  of  the  uri- 
nary and  genital  organs  terminate  in  the  internal  iliac  veins. 

The  vesical  veins,  according  to  Gillette,  consist  of  three 
plexuses — the  submucous,  the  intermuscular,  and  the  sub- 
peritoneal plexus.  The  submucous  plexus  is  made  up  of 
venules  from  the  capillary  network  of  the  mucous  mem- 
brane. At  the  lower  fundus  of  the  bladder  the  meshes  of 
this  network  are  much  closer  than  in  other  parts  and  over- 
lie each  other.  At  the  vesical  trigone  and  around  the 
vesico-urethral  orifice  the  network  is  most  highly  developed. 
This  explains  the  abundance  of  the  haemorrhage  which 
sometimes  occurs  after  lithotripsy,  and  also  the  spontane- 
ous vesical  haemorrhages  which  now  and  then  occur  in  men 
of  advanced  years. 

The  intermuscular  plexus  arises  in  part  from  the  venules 
of  the  muscular  coats,  and  in  greater  part  from  the  sub- 
mucous plexus.     The  principal  veins  of  the  intermuscular 


15 


plexus  follow  tlie  course  of  tlie  columns  of  the  internal  mus- 
cular layer. 

The  subperitoneal  plexus  comprises  a  large  number  of 
satellite  veins  which  descend  from  the  summit  toward  the 
lower  fundus  of  the  bladder.  These  veins  are  upon  the  an- 
terior, posterior,  and  lateral  portions  of  the  bladder.  They 
often  cause  troublesome  hcemorrhage  in  epicystotomv.  The 
anterior  veins  terminate  in  the  plexus  of  Santorini,  the  pos- 
terior in  the  plexuses  which  underlie  the  seminal  vesicles, 
and  the  lateral  end  in  the  lateral  prostatic  plexuses.  In  the 
lateral  plexuses  small  calcareous  concretions  called  phlebo- 
lites  are  frequently  found. 

The  anatomical  relations  of  the  prostatic  plexus  and  the 
large  veins  from  the  plexus  of  Santorini,  which  run  along 
the  sides  of  the  prostate,  should  be  borne  in  mind  during 
the  operations  of  lateral  and  bilateral  lithotomy,  for,  in 
case  the  incision  of  the  prostate  should  happen  to  be  ex- 
tended beyond  its  limits,  an  injury  of  the  plexus  would 
prove  a  source  of  serious  haemorrhage.  This  accident  has 
occurred  in  the  hands  of  skilKul  surgeons. 

The  veins  of  the  urethra  and  penis  pass  under  the  pubic 
arch  and  open  into  and  constitute  some  of  the  afferent  ves- 
sels of  the  plexus  of  Santoriai.  These  afferent  veins  are 
the  dorsal  vein  of  the  penis  and  some  veins  from  the  cav- 
ernous bodies  of  the  penis  and  from  the  bulb  of  the  urethra. 
The  anterior  vesical  veins,  together  with  certain  intrapelvic 
veins  which  also  communicate  with  the  obturator  veins,  are 
among  the  afferent  veins  of  Santorini's  plexus.  The  efferent 
veins  of  this  plexus  are  comprised,  says  Sappey,  in  four 


16 


groups.  Two  groups,  composed  of  tlie  largest  veins,  run 
along  the  sides  of  the  prostate ;  the  other  two  follow  the 
ischio-pubic  rami  and  constitute  the  origin  of  the  internal 
pudic  veins.  All  of  these  terminate  in  the  internal  iliac 
veins.  The  plexus  of  Santorini  presents  on  section  a  coarse 
trabecular  appearance,  and  the  trabeculse  w^hich  are  the 
walls  of  dilated  veins  are  rich  in  smooth  muscular  tissue, 
which  adds  much  to  their  strength. 

Lymphatic  vessels  have  been  traced  in  all  the  urinary 
and  genital  organs  except  in  the  mucous  membrane  of  the 
bladder  and  ureters.  Some  of  these  organs  are  much  more 
bountifully  supplied  with  lymphatics  than  others,  notably 
the  external  organs. 

In  affections  of  the  urethra,  penis,  and  scrotum,  the 
lymphatics  play  a  most  important  role,  and  this  fact  should 
be  kept  alive  in  the  mind  of  the  surgeon.  To  convey  an 
adequate  idea  of  the  extent  of  the  lymphatic  system  of  the 
external  uro-genital  organs,  the  following  is  abstracted 
from  Sappey's  Anatomy : 

No  part  of  the  cutaneous  surface  is  so  rich  in  capillary 
absorbent  vessels  as  the  scrotum.  These  vessels  take  up 
such  a  considerable  part  in  the  formation  of  the  scrotum 
that  it  seems  to  be  almost  exclusively  composed  of  lym- 
phatics. From  this  rich  ■  network  emerge  on  each  side  of 
the  median  line  ten  or  twelve  lymphatic  trunks,  which  pass 
obliquely  in  front  of  the  spermatic  cord  and  lose  themselves 
in  the  inferior  inguinal  glands. 

The  superficial  lymphatics  of  the  penis  originate  in  its 
integument,  and  are  especially  numerous  in-the  prepuce  ;  the 


17 


radicles  arising  therefrom  end  in  the  trunks  that  run  along 
the  dorsum  of  the  penis.  The  lymphatics  of  the  glans  penis 
are  remarkable  for  their  size  and  number,  and  are  disposed 
in  two  layers — a  superficial  layer,  consisting'  of  capillary  radi- 
cles, and  a  submucous  layer,  of  larger  radicles.  Both  layers 
are  continuous,  at  the  meatus  urinarius,  with  the  network 
of  the  urethral  mucous  membrane.  The  deep  layer  is  the 
starting  point  of  multiple  trunkules  which  converge  from 
before  backward  and  from  without  inward  toward  the  fre- 
num,  where  they  unite  with  other  branches  from  the  urethra, 
forming  what  is  called  by  Panizza  the  lateral  plexus  of  the 
frenum. 

The  capillary  lymphatics  of  the  urethra  extend  through- 
out its  entire  mucous  membrane,  forming  a  network  which, 
at  the  meatus,  is  continuous  with  the  absorbents  of  the  glans 
penis.  These  lymphatic  vessels  and  those  of  the  glans  con- 
verge to  the  lateral  plexuses  of  the  frenum  which  send 
trunks  to  the  dorsum  of  the  penis,  these  trunks  being  the 
afferent  vessels  to  the  inguinal  glands  above  Poupart's  liga- 
ment. This  peculiar  disposition  of  the  lymphatics  of  the 
urethra  and  penis  explains  why  venereal  ulcerations  so  con- 
stantly show  themselves  on  the  sides  of  the  frenum,  and 
how  the  inguinal  glands  become  involved  ;  why  urethritis 
begins  so  constantly  in  the  fossa  navicularis ;  why  this  affec- 
tion, in  certain  individuals,  is  accompanied  by  tumefaction 
of  the  inguinal  glands  ;  how,  after  being  very  circumscribed 
in  its  inception,  it  generally  extends  from  before  backward 
to  invade  little  by  little  the  whole  urethral  canal ;  finally, 
how  this  same  affection  may  extend  itself  to  the  testicles, 


18 


for  tlie  seminal  vesicles,  the  spermatic  canals,  and  tlie  tes- 
ticles are  not  less  rich,  in  absorbent  vessels  than  tlie  glans 
and  urethra,  the  same  network  being  prolonged  to  the  semi- 
nal tubes  of  the  testicles.  Therefore  urethritis  may  be  re- 
garded as  a  veritable  angeioleucitis. 

The  rrxcTiox  of  the  urinary  apparatus  consists  in 
the  excretion  and  expulsion  of  effete  substances  from  the 
organism,  these  being  separated  from  the  blood  by  the  kid- 
neys, which'  then  filter,  also  from  the  blood,  a  sufficiency  of 
water  to  dilute  and  wash  them  from  the  uriniferous  tubes 
into  the  calices  and  pelves  of  the  ureters,  thence  into  the 
bladder,  where  this  composite  fluid  called  the  urine  accu- 
mulates at  the  rate  of  from  an  ounce  and  a  half  to  two 
ounces  an  hour  and  at  length  becomes  a  burden  to  the  in- 
dividual, who  expels  it  voluntarily  through  the  urethra. 
Thus  is  accomplished  the  terminal  act  of  the  function 
of  urination.  The  proportion  of  excreta  to  the  aqueous 
element,  though  variable,  is  ordinarily  not  far  from  one 
in  twenty-four.  The  quality  and  quantity  of  urine  ex- 
creted are  subject  to  great  variation  in  different  persons, 
and  at  different  times  in  the  same  person.  A  medium- 
sized,  healthy  adult  male  expels  from  his  bladder  from 
thirty-six  to  forty-eight  ounces  of  urine,  with  an  average  of 
forty-two  ounces,  a  day,  urinating  from  four  to  six  times 
during  the  period  of  twenty-four  hours,  and  occupying  about 
twenty  seconds  for  each  act  of  urination  when  the  quantity 
of  urine  to  be  expelled  does  not  exceed  nine  ounces.  Young 
adults  often  retain  eighteen  and  even  twenty  ounces  of  urine 


19 


without  inconvenience,  and  many  men,  up  to  the  age  of  six- 
ty, urinate  only  three  times  in  the  twenty-four  hours,  twelve 
or  fourteen  ounces  each  time.  Ordinarily,  any  marked  de- 
viation in  quantity,  quality,  frequency,  or  freedom  of 
emission  constitutes  functional  derangement,  arising  from 
extreme  seasonal  variations,  improper  alimentation,  the 
ingestion  of  certain  medicinal  agents  or  of  poisons,  insuffi- 
cient exercise,  excess  of  exercise,  mental  perturhations,  in- 
juries, errors  in  the  nutritive  process,  or  organic  diseases. 

The  season  of  the  year  exerts  no  little  influence  on  the 
quantity  of  urine  excreted  by  healthy  subjects.  In  very  cold 
weather  the  aqueous  constituent  of  urine  is  increased,  while 
in  hot  weather,  the  individual  perspiring  abundantly,  it  is 
decreased,  the  saline  elements  remaining  the  same,  or  very 
nearly  so,  in  either  case.  In  the  first  case  the  specific  grav- 
ity of  the  urine  is  lessened,  and  in  the  second  case  it  is 
increased.  X^rine  of  low  specific  gravity  causes  vesical  irri- 
tation, with  unduly  frequent  desire  to  urinate,  and  the  same 
occurs  in  the  case  of  urine  of  inordinately  high  specific 
gravity.  Certain  articles  of  diet,  when  freely  used,  are 
known  to  greatly  increase  the  quantity  of  urine  in  healthy 
persons,  notably  the  water-melon.  In  one  instance,  the  juice 
of  two  pounds  of  water-melon  ha-ving  been  ingested,  three 
pints  of  urine  passed  in  three  hours  at  four  acts  of  urina- 
tion, each  time  giving  rise  to  marked  vesical  and  urethral 
uneasiness  which  lasted  at  least  fifteen  minutes.  In  view 
of  these  facts,  persons  suffering  from  renal  disease  should 
be  cautioned  against  making  too  free  use  of  aliments  which 
possess  diuretic  properties. 


20 


Oliguria,  to  a  moderate  extent,  is  caused  by  tlie  use  of 
several  of  the  food  vegetables.  Asparagus,  for  instance, 
when  freely  ingested,  bas  been  known  to  cause  diminution 
instead  of  increase  of  the  watery  element  of  the  urine,  and 
tbiere  are  other  articles  of  food  which  produce  the  same  effect. 

Qualitative  changes  also  occur  from  the  use  of  aliment- 
ary substances.  An  exclusive  meat  diet  sooner  or  later 
causes  hyperlithuria  in  man.  The  urine  of  carnivorous  ani- 
mals abounds  in  uric  acid.  But  certain  vegetables — such 
as  asparagus,  sorrel,  and  garden  rhubarb — cause  transitory 
oxaluria.  In  directing  the  diet  of  invalids,  the  foregoing 
facts  are  worthy  of  earnest  consideration. 

Medicinal  agents,  internally  administered,  for  diseases 
affecting  organs  other  than  the  urinary,  often  act  injuriously 
upon  the  urine,  and  thus  disturb  the  urinary  function. 
Among  these  agents  may  be  mentioned  cantharides.  Even 
when  applied  externally,  in  the  form  of  blisters,  the  active 
principle  of  cantharides  has  been  known  to  be  absorbed  in 
sufficient  quantity  to  produce  dysuria  and  strangury.  Bella- 
donna, used  too  freely,  causes  retention  of  urine.  Opium 
possesses,  among  its  properties,  that  of  causing  oliguria,  and 
the  diminution  of  the  aqueous  element  induced  by  the  pro- 
longed and  excessive  use  of  this  drug  sometimes  renders 
the  urine  irritating  to  the  extent  of  producing  cystitis. 
Spirits  of  turpentine,  given  freely  by  mouth  or  rectum,  has 
provoked  strangury  and  hsematuria.  The  too  free  ingestion 
of  copaiba  and  other  balsamics  for  the  cure  of  urethritis 
has  caused  grave  disturbance  of  the  urinary  function,  and 
even  fatal  renal  disease. 


21 


Mental  concentration  is  well  known  to  cause  polyuria. 
Brain  workers  urinate  frequently  and  abundantly,  and  their 
urine  is  generally  of  low  specific  gravity. 

A  sudden  impression  upon  the  nervous  system — as  from 
anger,  fear,  injury,  etc. — so  increases  the  blood-pressure 
upon  the  kidneys  as  often  to  cause  a  marked  increase  in 
the  urinary  excretion.  From  certain  injuries,  particularly 
those  of  the  head,  the  urinary  excretion  is  greatly  increased, 
and  the  attendant  shock  so  paralyzes  sensation  that  reten- 
tion of  the  increased  urine  ensues.  The  first  duty  of  the 
surgeon  in  such  a  case  is  to  catheterize  his  patient  and  re- 
lieve the  bladder,  which  would  otherwise  become  inordi- 
nately distended  in  a  few  hours. 

Errors  in  the  nutritive  function  lead  alike  to  hyper- 
lithuria,  oliguria,  polyuria,  glycosuria,  and  their  conse- 
quences. Persistent  hyperlithuria  leads  to  or  aggravates 
pre-existing  cystitis,  urethritis,  and  urethral  stenosis,  and  is 
the  parent  of  certain  vesical  stones.  In  oliguria,  polyuria, 
and  glycosuria  the  urine  possesses  irritating  properties  that 
will  be  stated  later.  Various  diseases  of  other  organs — 
such  as  the  heart,  lungs,  and  liver — react  in  sundry  ways 
upon  the  urinary  apparatus,  disturb  its  function,  and  finally 
damage  permanently  some  of  its  organs,  notably  the  kid- 
neys. Obstruction  to  the  urinary  flow — as  from  a  stricture, 
injurj^  of,  or  foreign  body  in,  the  urethra,  or  from  enlarge- 
ment of  the  prostate — disturbs  the  function  by  causing  un- 
duly frequent  and  difficult  urination,  or  even  retention  of 
urine. 


22 


TI. 

Outline    of  the   General    Pathology   of   the 
Urinary  Apparatus. 

General  patliology,  the  foundation  of  special  patliolo- 
gy,  indicates  the  nature  and  constituent  elements  of  mor- 
bid processes,  and  therefore  their  names  and  classes.  From 
its  study  are  deduced  general  principles  for  guidance  in 
special  pathology.  It  establishes  the  technical  language 
and  constitutes  the  chief  part  of  the  science  of  medicine. 
It  has  for  its  basis  bio-chemistry,  physiology,  embryology, 
and  histology.  A  fair  knoTvledge  of  each  of  these  branches 
of  biology  is  indispensable  to  the  right  understanding  of 
the  processes  of  disease. 

To  bio-chemistry  and  physiology  it  is  not  now  necessary 
to  do  more  than  allude,  but  to  the  cardinal  points  in  the 
principles  of  embryology  and  histology  it  is  proper  that  a 
little  space  be  devoted  as  an  introduction  to  the  arrange- 
ment of  the  subjects  of  future  examination. 

It  is  well  known  that  the  elementary  tissues  of  the  hu- 
man body  are  all  derived  from  a  primordial  ovule,  which, 
originally  spherical  in  form,  undergoes  segmentation  soon 
after  its  fecundation.  This  ovule  then  undergoes  certain 
changes  of  form  and  size  by  invagination  of  one  of  its 
halves  into  the  other,  giving  rise  to  what  is  called  the  gas- 
trula.  At  this  period  of  the  life  of  the  blastodermic  vesicle, 
three  parts  consisting  of  cells  are  specialized,  to  wit :  the  epi- 
blast-,  the  hypoblast,  and  the  mesoblast.  From  the  epiblast 
arisejthe  epidermic  covering  of  the  body  and,  it  is  said, 


23 

also  the  brain  ;  from  the  hypoblast  is  formed  the  epithelium 
of  the  internal  mucous  membranes  ;  and  from  the  mesoblast 
come  the  blood-cells,  the  endothelial  or  connective  tissues 
(comprising-  mucous,  glious,  fibrous,  cartilaginous,  and  osse- 
ous tissues),  muscle  tissue,  and  nerve  tissue.  Many  of  the 
cells,  particularly  those  derived  from  the  mesoblast — nota- 
bly the  blood-cells — are  disseminated  in  the  tissues  of  the 
body,  and  play  a  most  important  part  in  the  morbid  pro- 
cesses, some  of  them  retaining  their  embryonic  character. 

The  cells  which  exist  in  the  fully  developed  human  body 
may  be  enumerated  in  accordance  with  their  form  as  fol- 
lows :  spheroidal,  discoid,  oval,  irregular  multinucleated, 
polygonal,  fusiform,  unipolar,  bipolar,  multipolar,  cylindri- 
cal, and  squamous  cells.  These  cells,  in  a  more  or  less  modi- 
fied state,  exist  in  diseased  tissues,  or  rather,  in  this  altered 
state,  constitute  disease  of  most  of  these  tissues.  The  mor- 
bid processes  consist  in  alterations  in  the  blood,  disturb- 
ances in  the  circulatory  apparatus,  pathengenetic  alterations 
of  structure,  retrograde  metamorphoses,  tumors  (comprising 
neoplasmata,  adenomata,  cystomata,  and  blastomata),  con- 
cretions, injuries,  the  lodgment  of  foreign  bodies,  parasitic 
invasion,  monstrosities,  and  functional  disorders. 

To  be  abreast  of  the  advances  made  toward  a  better 
knowledge  of  these  morbid  processes,  and  prior  to  the  con- 
sideration of  special  diseases  of  particular  urinary  organs, 
an  introspection  of  their  general  pathology  will  be  conducted 
in  accordance  with  the  following  division :  1,  phlegmasic ; 
2,  stenotic  ;  3,  auxetic  ;  4,  echmatic ;  5,  ectatic  ;  6j  lithic  ; 
7,  neoplasm  atic ;  8,  adenic  ;  9,  blastomatic  ;  10,  cystic;  11, 


24 


entozoic  ;  12,  toxic;  13,  traumatic;  14,  allotrylic ;  15,  tera- 
tic  ;  and  16,  functional  affections  of  the  urinary  apparatus. 

1 .  The  term  pJilegmasic  affection  is  intended  to  convey 
the  idea  of  a  morbid  process,  one  of  the  local  nutritional 
changes  which,  when  visible  and  tangible,  is  ordinarily  char- 
acterized by  heat,  redness,  swelling,  and  pain,  and  which  is 
now  believed  by  many  pathologists  to  be  generally  caused 
by  microbic  invasion. 

Admitting  that  microbia  generally  constitute  an  impor- 
tant factor  in  the  causation  of  phlegmasic  action  clearly  im- 
plies that  they  are  not  invariably  the  exciting  agents  in  this 
nutritional  change.  To  what  else,  then,  besides  microbia, 
can  phlegmasic  action  be  attributed  ?  It  is  well  known  that 
acute  phlegmasic  action  very  frequently  becomes  chronic  or 
ends  in  sclerosis  and  contraction  of  tissues  without  suppu- 
ration, and  that  microbia  are  not  found  in  these  abnormal 
tissues.  Further,  that  in  certain  deep-seated  purulent  col- 
lections microbia  are  not  always  found.  Suppurative  phleg- 
masia has  been  experimentally  produced  and  no  microbia 
found  in  the  pus.  Does  not  the  explanation  rest  in  the  fact 
that  individual  human  cells,  like  individual  men,  sicken,  un- 
dergo nutritional  alterations,  or  even  starve  to  death,  owing 
to  insufficient  pabulum  or  to  its  exclusion  by  the  sudden 
plugging  of  a  neighboring  blood-vessel,  and  are  cast  away 
if  there  be  a  proper  channel  for  their  exit,  otherwise  they 
may  be  devoured  by  leucocytes  or  taken  up  as  effete  mate- 
rial and  excreted  ?  Are  not  some  of  the  phenomena  of  ami- 
crobic  phlegmasia,  such  as  the  occurrence  of  rigors  and  fe- 
brile reaction,  due  to  the  effect  of  the  animal  alkaloids  that 


25 


so  often  result  from  tissue  decay  ?  Bio-chemists  assert  that 
one  fifth  of  the  normal  human  body  is  in  a  necrotic  state 
and  that  man  exists  only  by  virtue  of  the  metabolic  action 
which  is  constantly  going  on  in  the  organism  ;  this  death 
and  regeneration  of  tissue  being  molecular,  gradual,  and  con- 
tinuous, and  the  eifete  material  being  eliminated  by  differ- 
ent apparatuses  of  the  body.  From  interruption  of  this 
elimination  and  from  inability  of  the  human  cell  to  resist 
the  effect  of  certain  infections,  of  injuries,  or  of  poisons, 
doubtless  arise  many  of  the  phlegmasise. 

Of  the  several  hypotheses  respecting  phlegmasic  pro- 
cesses, the  last,  based  on  Cohnheim's  illustration  of  the  emi- 
gration of  leucocytes,  offered  by  Mr.  J.  Bland  Sutton,  seems 
the  most  rational. 

The  colorless  blood-corpuscles,  leucocytes,  which  are 'en- 
dowed with  amoeboid  properties,  constitute  the  most  impor- 
tant of  the  factors  of  phlegmasic  processes,  and  how  they 
emerge  through  stomata  in  the  walls  of  the  capillary  blood- 
vessels has  been  fully  explained  and  demonstrated  by  Cohn- 
heim  and  photographed  by  Woodward.  Pathologists  of 
to-day  are  disposed  to  regard  phlegmasic  processes  as  con- 
servative, as  having  a  tendency  to  repair  such  mischief  as 
may  be  inflicted  by  foreign  bodies,  or  by  tissues  that  have 
died  from  want  of  adequate  sustenance  or  from  violence. 
The  dead  tissues  or  the  foreign  substances,  be  the  latter 
micro-organisms,  their  ptomaines,  or  any  other  extraneous 
objects,  as  so  well  set  forth  by  Mr.  Sutton,  are  at  once  at- 
tacked by  migrated  leucocytes  which  strive  to  ingest  and 
digest  the  offenders ;  but  it  sometimes  happens  that  many 


26 


of  these  leucocvtes  die  in  tlie  struggle  or  are  so  numerous 
as  to  crowd  themselves  and  the  ambient  tissues  to  death, 
and  form  what  is  called  pus,  and  a  slough.  If,  however,  the 
leucocytes  prevail  in  the  struggle,  resolution  occurs.  They 
undergo  fatty  degeneration,  are  absorbed  by  the  lymphatics, 
and  thus  disappear,  leaving  the  parts  as  nearly  as  can  be  in 
their  former  state.  The  leucocytes  do  not  always  undergo 
this  fatty  degeneration,  but  are  sometimes  transformed  into 
scar  tissue  which  tends  to  contract  and  cause  shriveling  of 
the  surrounding  parts. 

In  the  case  of  phlegmasia  of  mucous  membranes  great 
numbers  of  leucocytes  mate  their  way  from  the  subepithe- 
lial capillaries,  and,  by  virtue  of  their  amoeboid  properties, 
reach  the  surface  of  the  membrane,  by  passing  through  sto- 
mata  between  the  epithelial  cells,  to  attack  and  devour  for- 
eign invaders,  but  find  "themselves  in  an  unhabitable  terri- 
tory, and,  like  a  disorganized  mob,  are  scattered  in  all 
directions  to  perish  and  be  cast  away.  This  accounts  for 
the  abundant  suppuration  in  phlegmasia  of  mucous  mem- 
branes. 

The  phenomena  of  visible  and  tangible  phlegmasia  have 
been  explained  as  follows :  The  heat  is  owing  to  increased 
tissue  oxidation ;  the  redness,  to  blood  stasis ;  the  swelling, 
to  an  exudate ;  and  the  pain,  to  mechanical  pressure  of 
nerve  twigs  by  the  exudate. 

Phlegmasise  are  designated  superacute  when  the  phe- 
nomena of  heat,  redness,  swelling,  and  pain  are  intensified 
in  the  highest  degree ;  acute,  when  these  phenomena  are 
fully  characterized,  but  of  less  intensity  than  in  the  super- 


27 


acute,  both  being-  of  comparatively  short  duration ;  sub- 
acute, when  the  phenomena  are  not  all  apparent  or  are  mild 
in  character  ;  and  chronic,  when,  after  the  violence  of  super- 
acute  or  acute  phlegmasia  has  expended  itself,  resolution  is 
very  slow  or  indefinite.  Though  the  chronic  is  ordinarily 
the  continuance,  in  a  mild  form,  of  the  superacute,  acute, 
or  subacute  phlegmasia,  it  often  begins  without  previous 
superacute,  acute,  or  subacute  phlegmasia,  and  the  morbid 
process  lasts  an  indefinite  time. 

Chronic  phlegmasia  is,  therefore,  a  variation  in  degree 
rather  than  in  kind,  all  the  phenomena  of  the  acute  types 
existing,  but  in  a  lesser  degree.  Its  designation  chronic 
implies  its  quality  of  persistency. 

In  early  times  diseases  were  subdivided  into  subacute, 
lasting  from  twenty-one  to  forty  days  ;  acute,  lasting' four- 
teen days  ;  sub-very-acute,  lasting'  seven  days ;  very  acute 
or  superacute,  lasting  two,  three,  or  four  days ;  and  chronic, 
those  which  are  prolonged  beyond  the  fortieth  day. 

The  expressions  subacute,  acute,  and  superacute  phleg- 
masia now  have  reference  to  the  intensity  rather  than,  as 
formerly,  to  the  duration  of  the  affection. 

The  evolution  of  acute  phlegmasia  is  characterized  by 
four  distinct  stages  or  periods. 

The  first  stage  is  called  the  period  of  incubation — the 
hatching,  as  it  were,  of  the  phlegmasia — the  preparatory 
stage  ;  it  may  last  a  few  hours  or  several  days.  It  begins 
at  the  moment  of  contagion — of  the  advent  of  a  foreign  in- 
truder, or  of  whatever  else  may  be  the  irritant,  for  an  irri- 
tant is  necessary  to  the  development  of  phlegmasic  action. 


28 

In  tlie  beginning  there  is  an  increased  afflux  of  blood  to 
tbe  part  irritated.  If  the  irritant  is  removed,  the  pbleg- 
masic  process  is  cut  short  almost  at  its  inception.  The 
word  deliquescence  may  properly  be  used  to  express  the 
jdea  of  sudden  cessation  of  phlegmasic  action — its  melting 
away.  A  good  example  of  this  is  in  the  case  of  lodgment 
of  a  foreign  body  under  the  eyelid.  In  less  than  an  hour 
there  is  congestion  of  blood  in  the  conjunctival  vessels  and 
excessive  lacrymation.  If  the  foreign  body  is  at  once  ex- 
tracted, this  congestion  soon  decreases  and  ceases  in  two  or 
three  hours.  Another  example  is  the  entrance  of  a  puden- 
dal hair  into  the  urethra,  causing  an  almost  intolerable  itch- 
ing and  a  free  flow  of  mucus.  Soon  after  the  hair  is  re- 
moved the  irritation  is  relieved  and  the  mucous  flow  ceases. 
The  penetration  of  the  tissues  by  foreign  bodies,  be  they 
organic  or  inorganic,  gives  rise  to  this  afiiux  of  blood  and 
congestion  necessary  to  the  effusion  of  serum  and  the  mi- 
gratory process  of  the  leucocytes.  The  incubation  is  then 
ended,  the  phlegmasia  is  hatched,  and  the  second  stage 
begins. 

The  second  stage  is  called  the  period  of  increase.  Dur- 
ing this  period,  which  lasts  from  two  to  six  days,  the  four 
phenomena  are  manifested  and  become  more  and  more  in- 
tense. It  is  during  this  period  of  increase  that  the  leu- 
cocytes are  most  active.  A  violent  struggle  goes  on  be- 
tween them  and  the  intruder  until  the  phlegmasia  has 
reached  its  highest  point — its  acme. 

The  third  stage  is  called  the  static  period — the  acme. 
During  this  static  period,  which  may  last  only  a  few  hours, 


29 


a  day  or  two,  or  a  week,  tlie  contest  is  decided  either  by 
resolution,  by  gangrene,  or  by  suppuration. 

The  fourth  stage,  called  the  period  of  decline,  lasts  much 
longer  than  any  of  the  former.  The  beginning  of  this  stage 
is  the  beginning  of  resolution.  The  migrated  leucocytes 
are  victorious,  but  doomed  to  death  soon  after  their  victory, 
for  resolution  is  effected  by  fatty  degeneration  of  these 
leucocytes,  which  in  that  state  are  absorbed  by  the  lym- 
phatics. When  resolution  is  incomplete  the  leucocytes  do 
not  all  undergo  fatty  degeneration,  but  are  transformed  into 
scar  tissue,  or,  there  being  still  a  source  of  irritation,  newly 
migrated  leucocytes  reach  the  surface,  die,  and  are  dis- 
charged as  pus,  particularly  in  phlegmasia  of  mucous  mem- 
branes. 

When  leucocytes  have  undergone  fatty  degeneration 
they  sometimes  are  not  absorbed,  but  undergo  caseation 
and  afterward  calcareous  infiltration,  and  even  when  they 
are  organized  into  scar  tissue  this  also  occasionally  under- 
goes calcareous  infiltration.  The  calcareous  mass  is  then 
encysted  and  thereby  rendered  innocuous.  This  calcareous 
infiltration,  often  erroneously  called  ossific  transformation, 
occurs  in  the  cavernous  bodies  of  the  penis,  in  the  vaginal 
tunic  of  the  testicle,  and  in  other  parts  of  the  body. 

When  gangrene  occurs,  newly  migrated  leucocytes  at- 
tack the  dead  part  and  tend  to  loosen  it  from  the  living 
tissues  until  it  is  cast  away. 

PhlegmasifB  of  the  urinary  organs  are  engendered  by 
general  dyscrasise,  by  parasitic  irfvasion  (vegetable  and  ani- 
mal), by  other  local  irritants,  by  injjiries,  or  by  contagion. 


30 


and  in  their  turn  engender  local  affections,  sucli  as  stenoses, 
auxeses,  eclimases,  ectases,  etc.,  as  well  as  functional  dis- 
orders. 

2.  A  stenosis  is  a  contraction.  This  term  is  applied  to 
contraction  of  hollow  viscera  or  of  ducts.  Stenotic  affec- 
tions proceed  generally  from  phlegmasic  action,  and  are 
pathic  conditions  of  hollow  viscera  and  of  excretory  ducts, 
as  in  the  cases  of  the  permanently  contracted  bladder  with 
diminution  of  its  capacity,  and  of  stenosis  or  stricture  of 
the  ureters  and  of  the  urethra.  A  stenotic  affection  may  or 
may  not  be  obstructive.  Stenotic  affections  are  sometimes 
congenital,  sometimes  traumatic,  but  are  most  frequently 
the  offsprings  of  pre-existing  morbid  conditions,  as,  for  in- 
stance, the  stenosis  of  the  bladder  which  springs  from 
phlegmasia  of  that  viscus,  or  the  stenosis  of  the  urethra 
resulting  from  urethritis. 

In  stenosis  of  the  bladder  there  is  not  only  permanent 
contracture  of  the  muscular  layers,  but  sclerosis  of  the  sub- 
mucous connective  tissue.  In  many  cases  there  is  augmen- 
tation of  the  muscular  element,  and  consequently  general 
thiclvening  of  the  walls  of  the  viscus.  This  condition  may 
be  properly  classed  with  that  of  diffuse  myomata. 

In  idiopathic  stenosis  of  the  urethra  there  is  not  a  mass 
of  inodular  tissue,  as  was  formerly  supposed,  but  a  layer  of 
scar  tissue  of  extreme  tenuity,  this  scar  tissue  resulting 
from  a  local  slow  retrograde  metamorphosis,  a  condition  of 
sclerosis,  tending  to  progressive  contraction  of  the  imper- 
fectly organized  plasma  of  circumscribed  acute  or  of  chronic 
urethral  phlegmasia.      This   imperfect   organization   is,  in 


31 


part,  owing  to  the  obstruction  of  blood  and  lymph  capil- 
laries by  the  mechanical  compression  exerted  by  the  leu- 
cocytes of  the  plasma.  The  sclerosis  may  involve  the 
mucous  membrane,  the  submucous  connective  tissue,  the 
spongy  substance,  or  all  three  layers.  In  traumatic  stenosis 
a  similar  condition  exists,  but  is  developed  with  much 
greater  rapidity,  the  scar  tissue  contracting  as  quickly  as 
that  resulting  from  burns.  In  idiopathic  as  well  as  in  trau- 
matic urethral  stenosis,  therefore,  it  may  be  confidently  as- 
serted that  there  is  nothing  to  be  absorbed,  but  rather  that 
there  is  need  of  regeneration  of  tissue,  and  to  promote  such 
regeneration  the  surgeon  makes  an  artificial  gap  in  the 
urethra  by  divulsion,  or  by  incision  of  the  constricted  part, 
which  Nature  fills  and  thus  splices  with  new  cicatricial 
tissue. 

3.  An  auxesis  is  an  enlargement.  Auxetic  affections  of 
the  urinary  organs  are  states  of  enlargement  which  gener- 
ally interfere,  in  varying  degrees,  with  the  uses  of  these 
organs,  and  are  the  outcome  of  phlegmasic,  echmatic,  neo- 
plasmatic,  adenic,  cystic,  or  traumatic  affection^.  How- 
ever, auxetic  action  is  sometimes  beneficent,  occurring  when 
one  of  a  pair  of  organs  is  destroyed,  as  in  the  case  of  loss 
of  one  kidney,  the  remaining  kidney  undergoing  compensa- 
tory auxesis  sufficient  to  enable  it  to  excrete  more  than  when 
its  fellow  was  sound.  Here  nephrauxe  is  the  reverse  of  a 
pathic  condition.  Prostatauxe,  on  the  contrary,  arises  from 
pathic  states  of  the  prostate  itself,  and  is  often  the  cause  of 
grave  disturbance  in  urination. 

4.  An  echmasis  is  an  obstruction.     Echmatic  affections 


32 


of  the  urinaiy  apparatus  are  states  of  obstruction  of  excre- 
tory ducts  arising  from  acute  phlegmasic  swelling,  from 
stenoses,  from  neoplasraata,  or  from  impaction  of  uroliths 
or  of  foreign  bodies.  Acute  prostatitis  causes  echmasis  of 
the  urethra  and  urethro-vesical  orifice,  and,  consequently, 
retention  of  urine.  Narrow  urethral  stenoses  give  rise  to 
sufficient  echmasis  of  the  urethra  to  cause  its  dilatation  be- 
hind the  seat  of  disease.  Neoplasmata  of  the  prostate,  with 
unequal  enlargement  of  its  lobes,  cause  urethral  or  urethro- 
vesical  echmasis.  Impaction  of  uroliths  in  the  ureter  causes 
echmasis  of  this  excretory  duct  and  consequent  retention  of 
urine,  inflammation,  and  ectasis  of  the  renal  pelvis.  For- 
eign bodies  in  the  urethra  cause  echmasis  and  retention  of 
urine.  Long-continued  echmasis,  even  when  incomplete, 
causes  permanent  ectasis  and  chronic  inflammation  behind 
the  point  of  obstruction,  and,  in  many  cases,  destruction  of 
the  upper  urinary  organs  and  death. 

5.  An  ectasis  is  an  expansion.  This  term  is  applied  to 
expansion  of  hollow  viscera  and  of  canals.  Ectatic  affec- 
tions are  conditions  of  expansion,  of  dilatation,  of  hollow 
viscera,  of  excretory  ducts,  of  lymphatic  and  blood  vessels, 
or  of  serous  cavities.  Ectatic  affections  are  due  to  phleg- 
masic  action,  or  to  echmasis  from  disease,  injury,  or  the 
lodgment  of  foreign  bodies.  Morbid  dilatation  of  the  blad- 
der, local  or  general,  belongs  to  the  order  of  ectatic  affec- 
tions. Ectasia  of  the  renal  pelves  is  often  caused  by  hydro- 
nephrosis and  pyonephrosis.  The  accumulation  of  serum 
in  the  tunica  vaginalis  testis  causes  ectasia  of  this  vaginal 
tunic. 


33 


6.  Lithic  affections  are  produced  by  the  formation  of 
concretions,  varying  greatly  in  density,  form,  and  size,  in 
crypts,  ducts,  or  cavities  of  the  human  body.  Those  now 
under  consideration  are  the  uroliths  and  prostatoliths. 

Uroliths  are  conci'etions  formed  from  the  salts  of  the 
urine  around  nuclei  which,  from  their  irritating  contact,  ex- 
cite a  copious  flow  of  tenacious  mucus,  serving  as  a  cement 
to  the  crystalline  or  to  the  amorphous  salts  of  which  they 
are  composed.  Prostatoliths  are  concretions  originating  in 
the  crypts  of  the  prostate. 

Lithic  affections  of  the  urinary  organs  should  be  studied 
under  the  following  heads  :  Those  caused  by  uroliths  of 
diathetic  origin,  those  caused  by  uroliths  of  accidental  ori- 
gin, and  those  caused  by  prostatoliths. 

The  uroliths  of  diathetic  origin  are  due  to  hyperlithuria, 
caused  by  disturbances  in  the  nutritive  function. 

The  uroliths  of  accidental  origin  are  due  to  stagnation 
of  urine,  to  tumors  of  the  bladder,  to  injuries,  or  to  the 
presence  of  foreign  bodies. 

Prostatoliths  are  due  to  the  death  of  sympexia,  which 
exist  normally  in  the  prostatic  crypts,  and  to  their  gradual 
increase  in  size  by  phosphatic  incrustation. 

7.  Neoplasmata  are  tumors  formed  by  cell  proliferation. 
Xeoplasmatic  affections  of  the  urinary  organs  comprise 
epithelial  neoplasmata,  endothelial  neoplasmata,  myoneo- 
plasmata,  and  angeioneoplasmata. 

The  epithelial  neoplasmaAa  are  the  polymorpho- cellular, 
the  cylindro-cellular,  and  the  squamo-cellular.  The  first 
two,    derived    from    the    epiblast    and    hypoblast,    contain 


34 


fibrous  tissue  and  are  malignant.  The  third  species  con- 
tains no  fibrous  tissue,  but  is  also  malignant.  The  lower  the 
grade  of  structure,  tlie  greater  the  malignity.  These  species 
have  their  varieties  and  subvarieties,  the  presence  of  more 
or  less  fibrous  tissue  constituting  the  variations  in  the  first 
two  species,  as  ino- epithelioma  (medullary  cancer)  and 
hyperino-epithelioma  (scirrhous  cancer).  The  subvarieties 
are  the  papillary  and  the  teleangeiectatic  (fungous  hfema- 
todes).  The  third  species,,  squamo- cellular  (epithelioma), 
derived  from  the  epiblast,  has  two  varieties,  myxoid  and 
keratoid  ;  and  one  subvariety,  papillary. 

The  idea  that  epitheliomata  are  provoked  by  microbic 
invasion  has  been  enunciated  by  several  bacteriologists,  and 
a  few  years  ago  a  German  bacteriologist  announced  the  dis- 
covery of  a  cancer  bacillus,  but  other  bacteriologists  have 
so  far  failed  to  find  a  specific  organism  in  cancer. 

"  The  term  cancer,"  says  Mr.  Sutton,  "  in  the  present 
day  is  restricted  to  tumors  resembling  formed  glands.  .  .  . 
Cancers  are  aberrant  glandular  formations,  and  may  not 
inaptly  be  defined  as  biological  weeds.  .  .  .  The  glandular 
nature  of  cancers  is  further  illustrated  by  the  fact  that  in 
their  intimate  structure  they  resemble  the  glands  in  the  im- 
mediate neighborhood.  Thus,  a  cancer  of  the  lip  resembles 
the  cutaneous  glands  ;  in  the  liver  it  mimics  the  liver ; 
mammary  cancer  resembles  imperfectly  the  secreting  tissue 
of  the  breast,  and  so  forth.  Cancers  are  downward  growths 
of  epithelium  into  the  subjacent  tissues." 

Endothelial  neoplasmata,  which  are  among  the  meso- 
blastic  new  growths,  are  ranked  with  desmoneoplasmata, 


35 


from  their  elements  being  embryonic  states  of  tlae  different 
forms  of  connective  tissue. 

Tbe  endothelial  neoplasmata  of  the  urinary  organs  are 
endothelioma,  inoma,  and  myxoma. 

The  genus  endothelioma  (sarcoma  or  endothelial  cancer) 
has  four  species,  the  globo- cellular,  the  fuso-cellular,  the 
giganto-cellular,  and  the  piano-cellular  (flat-celled  sarcoma 
or  endothelioma).  Only  the  first  three  occur  in  the  urinary 
organs.  The  globo-cellular,  small  and  large  celled  (round- 
celled  sarcoma),  has  five  varieties,  only  two  of  which  occur 
in  the  urinary  organs — ino-endothelioma  (round-celled  fibro- 
sarcoma), and  myxo-endothelioma  (round-celled  myxo-sar- 
coma) ;  and  two  subvarieties — papillary  and  teleangeiectatic. 
The  fuso-cellular,  small  and  large  celled  (spindle-celled  sar- 
coma), has  the  same  varieties  and  subvarieties  as  the  first 
species.  The  giganto-cellular  (giant-celled  sarcoma)  has 
the  same  varieties  and  subvarieties  as  the  first  and  second 
species. 

Mr.  Sutton  places  the  sarcomata  among  infective  tu- 
mors caused  by  micro-organisms,  and  says  :  "  Those  tumors 
which  pathologists  term  sarcomata  differ  from  those  pro- 
duced by  the  ray  fungus  in  the  following  particulars :  The 
micro-organism  or  causative  agent  has  not  yet  been  isolated, 
and  we  have  no  satisfactory  evidence  that  a  sai^oma  can 
be  inoculated  into  another  animal.  Nevertheless,  the  two 
forms  of  tumors  agree  in  the  general  principle  of  structure, 
disastrous  effects  upon  the  life  of  the  individual,  and  in  a 
tendency  to  infect  the  system.  Careful  research  wil 
probably  establish  before  very  long  a  poison  or  micro-or- 


36 


ganism  for  eacli  of  the  various  types  of  sarcoma.'"  He  is 
inclined  to  believe  that  these  tumors  are  the  products  of 
phlegmasic  action,  due  to  microbic  invasion,  and  further 
says :  "  To  put  the  matter  in  a  clear  form,  a  sarcoma  is 
probably  the  scene  of  action  of  a  violent  and  prolonged 
conflict  between  irritant  micro-organisms  and  leucocytes. 
I  say  probably,  because,  as  has  been  already  remarked, 
bacteriologists  have  not  yet  succeeded  in  isolating  a  special 
bacterium  for  sarcomata  in  general ;  that  such  agents 
will  soon  be  discovered  is  in  the  highest  degree  probable, 
because  in  recent  years  each  increase  in  the  list  of  infective 
granulomata  is  made  at  the  expense  of  sarcomata.  The 
structure,  mode  of  growth,  infective  properties,  and  manner 
in  which  these  tumors  destroy  life  clearly  coincide  with 
what  is  positively  known  with  regard  to  infective  granulom- 
ata. The  fact  that  sarcomata  make  up  the  greater  part 
of  tumors  occurring  in  wild  and  domesticated  animals  has, 
in  my  opinion,  a  very  significant  import  in  this  relation." 

Assuming  these  views  of  Mr.  Sutton  to  be  correct,  they 
do  not  necessarily  affect  the  classification  just  given  of 
sarcomata,  which  remain  endothelial  growths,  whatever 
may  be  their  cause. 

The  genus  inoma  (benign)  has  two  subgenera — circum- 
scribed inoma  and  diffuse  inoma.  These  two  subgenera 
have  two  species — the  piano-cellular  and  the  fasciculated. 
Each  species  has  five  varieties,  of  which  the  first  and  second 
occur  in  the  urinary  organs — viz.  :  endothelio-inoma  (malig- 
nant) and  myxo-inoma  (benign),  the  subvarieties  being  the 
papillary  and  teleangeiectatic. 


37 

The  genus  myxoma  has  two  species — the  monomorpho- 
ceUular  and  the  polymorpho-cellular.  The  two  species  have 
three  varieties — endothelio-myxoma  (malignant),  ino-myx- 
oma  and  lipo-myxoma  (both  benign),  and  two  sub^arieties — 
the  papillary  and  teleangeiectatic. 

A  myoneoplasma  is  a  new  growth  of  muscular  fibers, 
and  therefore  of  mesoblastic  origin. 

The  order  myoneoplasmata  has  one  genus,  myoma ;  two 
subgenera,  circumscribed  myoma,  diffuse  myoma ;  and  two 
sj)ecies,  rhabdomyoma,  leiomyoma  (all  benign),  each  species 
having  two  varieties,  inorrhabdomyoma  or  inoleiomyoma, 
circumscribed  or  diffuse,  as  the  case  may  be,  and  endothe- 
iorrhabdomyoma  or  endothelioleiomyoma,  generally  called 
myosarcoma  (malignant). 

If  Mr.  Sutton's  interpretation  of  the  nature  of  sarcomata 
is  correct,  then,  when  the  sarcomatous  element  constitutes 
sub  varieties  of  neoplasmata,  these  previously  benign  neo- 
plasmata  are  rendered  malignant  by  the  invasion  of  micro- 
organisms which  are  combated  by  migrated  leucocytes. 

Angeioneoplasmata  are  tumors  made  up  of  blood  or 
lymph  vessels,  and  are  of  mesoblastic  derivation. 

The  order  angeioneoplasmata  has  one  genus,  angeioma ; 
two  species,  hsematangeioma  and  lymphangioma ;  and  two 
varieties,  cirsoid  and  cavernous  (all  benign). 

8.  The  adenomata  constitute  a  class  of  tumors  having 
the  same  structure  as  the  glands  in  which  they  occur.  This 
structure  is,  however,  imperfectly  elaborated,  is  character- 
ized by  epithelial  hyperplasia,  and  tends  to  metamorphosis 
into  malignant  epithelioma,  which  occui's  as  soon  as  the  cells 


38 

have  broken  the  barrier  opposed  to  them  by  the  limiting 
membrane  of  the  acini. 

This  class  has  two  orders,  ectocoeliac  and  entocoeliac 
adenomata.  The  first  order  has  four  and  the  second  order 
six  genera,  each  generic  name  indicating  the  gland  affected. 
Only  three  of  the  entocoeliac  adenomata  occur  in  connection 
with  the  urinary  apparatus  :  lymphadenoma  (adenoma  of 
a  lymphatic  gland),  nephradenoma  (adenoma  of  the  kid- 
ney), and  myxadenoma  (adenoma  of  mucous  glands). 

Mr.  Sutton,  who  recognizes  the  existence  of  adenomata 
in  the  sense  in  which  the  term  is  used  above,  admits  their 
liability  to  be  transformed  into  cancers.  The  following  are 
his  comments  on  the  subject : 

"  In  young  individuals  we  find  occasionally  in  connec- 
tion with  a  functional  gland  a  tumor  which,  when  examined 
microscopically,  displays  all  the  features  peculiar  to  the 
gland  with  which  it  was  connected ;  the  only  point  in  which 
it  differs  is  that  the  adventitious  mass  is  impotent — that  is, 
it  can  not  produce  the  secretion  peculiar  to  the  gland  from 
which  it  arose.  Such  a  tumor  is  called  an  adenoma,  and 
receives  a  specific  name  according  to  the  gland  it  resembles 
— sebaceous,  mammary,  renal,  hepatic,  etc.  Adenomata 
may  attain  enormous  size  and  weigh  many  pounds.  As  life 
advances  the  mimicry  is  crude ;  the  cells,  instead  of  clothing 
the  alveoli  in  a  regular  manner,  are  tumbled  together  in  con- 
fusion. Such  tumors  are  cancers ;  they  grow  aimlessly, 
having  no  function  to  keep  them  in  subjection,  and,  being- 
poorly  supplied  with  blood-vessels,  undergo  degenerative 
changes,  and  the  cells,  being  dispersed  over  the  body,  may 


39 


reproduce,  in  remote  tissues  and  organs,  secondary  tumors 
resembling  tlie  original  cancer  from  which  they  arose." 

9.  Blastomata  are  infective  granulation  growths  invaded 
by  micro-organisms. 

The  blastomata  that  affect  the  urinary  organs  are  the 
syphilitic,  syphiloid,  and  tuberculous. 

Syphilis  is  a  toxsemia  caused  by  a  virus  deposited  upon 
an  abraded  cutaneous  or  mucous  surface  and  absorbed  into 
the  organism ;  it  is  therefore  a  general  dyscrasia.  It  is  due 
to  immediate  as  well  as  to  mediate  contagion,  and  the  na- 
ture of  its  virus  is  still  an  unsettled  question.  By  some  in- 
vestigators it  is  regarded  as  a  microbic  affection.  If  this 
view  is  correct,  a  ptomaine  of  syphilis  will  be  the  next  dis- 
covery. 

The  initial  lesion  of  syphilis  is  at  the  seat  of  inoculation 
and  appears  as  a  sclerosed  spot  called  chancre. 

Syphilis  is  often  transmitted  from  parent  to  offspring, 
and  in  that  case  is  generally  designated  as  hereditary. 

Lustgarten  thinks  he  has  discovered  a  bacillus  peculiar 
to  syphilis,  and  the  same  view  is  taken  by  Doutrelepont,  but 
other  investigators  do  not  confirm  this  view.  However, 
there  is  no  doubt  of  the  presence  of  sundry  micro-organisms 
in  syphilis  as  in  the  other  blastomata,  whose  granulation  tis- 
sue affords  them  abundant  sustenance,  for  the  microbia  are 
known  to  thrive  in  structures  of  low  vitality.  In  unclean 
subjects,  saprophytic  organisms  swarm  in  chancres  and  other 
kindred  lesions. 

Syphiloid  (chancroid  or  soft  chancre)  is  contagious,  but 
does  not  infect  the  whole  system,  as  syphilis  does.     The 


40 


nature  of  the  contagium  of  sypMloid  is  unknown.  Syphi- 
loid ulcers  are  infested  with  saprophytic  micro-organisms 
which  in  themselves  are  not  poisonous.  Syphiloid  is  con- 
tagious, both  mediately  and  immediately,  but  without  the 
long  period  of  incubation,  such  as  occurs  in  syphilis,  the 
lesion  showing  itself  within  forty-eight  hours  after  contact 
with  denuded  skin  or  mucous  membrane. 

Tuberculosis  is  now  believed  to  be  due  to  infection  by  a 
micro-organism  named,  in  1882,  by  Koch,  the  tubercle 
bacillus.  This  microzyme  is  supposed  to  enter  the  human 
organism  through  the  respiratory,  the  digestive,  the  genital, 
or  the  urinary  organs,  as  well  as  through  abrasions  or 
wounds  of  external  parts,  the  most  common  inlet  being 
the  respiratory  apparatus.  By  modern  pathologists  tuber- 
culosis is  regarded  as  a  phlegmasic  process,  which  they 
explain  as  follows :  As  soon  as  the  tubercle  bacilli  effect 
lodgment  in  the  tissues  their  irritating  presence  causes,  in 
the  ambient  capillaries,  an  increased  afflux  of  blood. 
These  capillaries  are  thereby  dilated,  and  the  stomata  at  the 
junction  of  endothelial  cells  allow  the  leucocytes,  by  a  tem- 
porary alteration  of  form,  to  effect  their  exit.  Thus  begin 
their  migration  and  their  warfare  with  the  bacilli  which 
they  ingest  and  digest.  If  victorious,  the  conflict  is  ended 
and  resolution  occurs.  If  the  leucocytes  are  not  able  to 
cope  with  a  large  aggregation  of  bacilli,  they  sometimes 
operate  its  encystment  by  their  own  conversion  into  scar 
tissue.  If  the  bacilli  are  too  numerous,  the  leucocytes  per- 
ish and  suppuration  ensues.  The  infection  then  becomes 
general  and  the  sufferer  succumbs.     The  presence  of  giant 


41 

cells  in  tubercles  is  explained  by  the  coalescence  of  numbers 
of  leucocytes. 

10.  Cysts  are  inclosed  spaces  whose  contents,  fluid  f)r 
solid,  are  circmnscribed  by  fibrous  tissue,  or  some  other 
more  or  less  complex  structure,  with  or  without  a  lining  of 
epithelium,  according  to  their  genesis.  There  are  five  or- 
ders of  cysts — epithelial,  endothelial,  degeneration,  parasi- 
tic, and  teratic  cysts,  among  which  are  the  dermoid. 

The  epithelial  cysts  occur  in  crypts  or  ducts  lined  with 
epithelium,  and  are  due  to  the  occlusion  of  a  duct,  and  con- 
sequent retention  and  accumulation  of  glandular  secretion. 
Epithelial  cysts  contain  more  or  less  cast-off  epithelium, 
sometimes  plates  of  cholesterin,  and  the  fluid  and  the 
solids  of  the  particular  secretion,  and  accidentally  blood. 
Their  variations  of  size  are  extreme. 

The  endothelial  are  exudation  cysts  formed  in  connect- 
ive-tissue spaces,  in  false  membranes,  and  in  obstructed 
lymphatics.  Their  contents  are  ordinarily  lymph,  and  ac- 
cidentally blood  is  superadded.  They  are  often  called  hy- 
gromata. 

The  degeneration  cysts  result  from  a  necrotic  process  in 
the  substance  of  organs,  and  often  of  neoplasmata,  and  their 
contents  are  the  products  of  disintegration  of  the  structure 
of  the  organ  or  neoplasma.  Some  degeneration  cysts  have 
fibroid  walls,  resulting  from  the  conversion  of  surrounding- 
leucocytes  into  scar  tissue  for  the  protection  of  adjacent 
parts.  The  encystment  of  tubercular  nodules,  of  foreign 
bodies — such  as  bullets,  fragments  of  glass  or  pottery,  of 
needles,  etc. — of  clots  of  blood,  of  cheesy  nodules,  etc.,  is 


42 


effected  in  this  manner  to  render  tliem  innocuous.  Para- 
sites, and  certain  monstrosities,  in  like  manner  and  for  tlie 
same  purpose,  undergo  encystment. 

11.  Entozoic  ijarasites  are  animals  living  within  and  at 
the  expense  of  the  body. 

The  entozoic  parasites  that  invade  the  urinary  organs 
are  the  Ecliinococcus  hominis,  the  Distoma  hwmatohium,  the 
Pentastoma  denticulatum,  and  the  Strongylus  gigas.  Filaria 
sanguinis  and  Trichina  spiralis  have  been  found  in  the  urine. 

These  entozoa  reach  the  human  organism  principally 
through  food  or  water  polluted  by  animals  that  are  infested 
with  these  parasites. 

Worms,  such  as  lumbrici,  or  joints  of  taenia,  have  passed 
from  the  intestine  into  the  bladder  and  have  been  found  in 
the  urine.  They  should  not  be  ranked  as  parasites  of  the 
urinary  organs,  since  they  enter  the  bladder  through  fistu- 
lous tracts.  In  young  female  subjects,  pin-worms,  infesting 
the  rectum,  have  been  known  to  make  their  way  to  the  vulva, 
and  finally  to  creep  into  the  bladder  through  the  urethra. 
In  both  cases  these  are  designated  as  erratic  worms. 

Larvae  of  flies,  introduced  into  the  bladder,  accidentally 
and  sometimes  designedly,  have  been  mistaken  for  para- 
sites. These  are  classed  as  spurious  worms.  The  Spirop- 
tera  Jiominis,  Diplosoma  crenatum^  and  Dactylius  aculeatus 
are  among  the  spurious  worms. 

12.  Poisons  are  substances,  either  organic  or  inorganic, 
which,  when  introduced  into  the  system  by  the  cutaneous, 
respiratory,  or  digestive  apparatus,  are  capable  of  produc- 
ino-  disease  or  death. 


43 


Some  poisons  are  very  irritating  to  the  urinary  tract, 
and  even  cause  structural  disease. 

Many  of  the  medicinal  drugs,  when  taken  in  large  doses 
or  when  used  for  a  long  time,  act  noxiously  upon  the  uri- 
nary organs,  particularly  those  that  are  freely  eliminated  by 
the  kidneys. 

Besides  the  ptomainic  poisons  derived  from  bacterial 
action,  there  are  other  virulent  poisons  to  which  the  name 
of  leucomaines  has  been  given  and  which  originate  in  the 
animal  economy  from  tissue  disintegration  without  the 
agency  of  bacteria.  These  leucomainic  poisons  cause  dis- 
eases which  have  been  named  autogenous,  and  the  nature 
and  course  of  which  are  daily  becoming  better  known  and 
interpreted,  thanks  to  the  labors  of  the  bio-chemists. 

13.  Traumatic  affections  are  hurts  caused  by  violence. 
But  the  use  of  this  term  is  generally  extended  to  designate 
structural  violence  inflicted  otherwise  than  by  a  wound. 
The  injury  may  be  effected  directly  or  indirectly  by  the 
fracture  of  a  bone,  by  contusion,  puncture,  perforation,  in- 
cision, laceration,  crunching,  cauterization,  or  congelation. 

14.  Allotrylic  affections  are  morbid  states  caused  by  the 
lodgment  of  foreign  substances  in  the  organism.  The 
foreign  substances  may  be  animate  or  inanimate,  organic  or 
inorganic. 

A  foreign  substance  may  enter  the  urinary  tract  by  the 
natural  route,  or  by  an  artificial  route  resulting  from  disease 
or  from  violence. 

15.  Teratic  affections  are  congenital  or  acquired  devia- 
tions from  the  essential  characteristics  of  organized  beings. 


44 

The  adjective  teratic  is  from  repas,  a  wonder,  a  marvel, 
a  monster,  and  monster  from  monstrum,  from  monstrare,  to 
show.  Therefore  teratism  or  monstrosity  is  properly  ap- 
plied to  any  anomaly  of  conformation,  whether  congenital 
or  acquired  from  disease  or  injury.  It  is  something  out  of 
the  ordinary  type,  to  gaze  at  and  marvelous. 

The  nature  of  monstrosities  can  be  well  understood  only 
after  adequate  study  of  the  earliest  stages  of  the  develop- 
ment of  organized  beings,  beginning  with  the  fecundated 
o\"nle  referred  to  at  the  opening  of  this  conference. 

The  human  ovule  is  subject  to  sundry  freaks,  just  as  is 
the  case  in  that  of  the  lower  animals  and  in  vegetable  seeds, 
and  in  it  is  to  be  detected  the  point  of  departure  of  some 
anomalies  which  are  found  in  the  embryo  and  in  the  fully 
developed  being. 

The  congenital  monstrosities  are  vices  of  primary  confor- 
mation, and  may  be  classed  as  follows  : 

1.  The  ectrogenic  :  Those  monstrosities  in  which  are 
absent  or  defective  certain  parts  belonging  to  the  normal 
body.  For  example,  the  absence  of  one  Mdney,  the  absence 
of  one  or  both  testicles,  the  absence  of  the  external  uro- 
genital organs,  etc. 

•2.  The  symphysic  :  Those  monstrosities  produced  by 
fusion  or  coalition  of  organs,  such  as  the  kidneys. 

3.  The  ceasmic  :  Those  monstrosities  in  which  the  parts 
that  should  be  united  remain  in  their  primitive  fissured  state, 
as  hypospadias  and  epispadias. 

4.  The  atresic :  Those  monstrosities  in  which  natural 
openings  are  occluded,  as  imperforate  urethra. 


45 


5.  The  hypei'genetic  :  Those  monstrosities  in  which  cer- 
tain parts  are  clisproportionately  large,  such  as  the  penis,  the 
testicles,  etc. 

6.  The  ectopic  :  Those  monstrosities  in  which  one  or 
more  than  one  part  may  be  abnormally  placed,  such  as  a 
kidney  or  both  kidneys,  a  testicle  or  both  testicles. 

7.  The  hermaphroditic  :  Those  monstrosities  in  which 
organs  of  both  sexes  exist. 

The  acquired  monstrosities  are  the  outcome  of  disease,  of 
violence,  or  of  operations  necessitated  by  diseased  conditions 
or  injuries,  and  may  be  classed  as  follows  : 

1.  The  ectrogenic :  Those  monstrosities  caused  by  the 
loss  of  some  part  from  disease,  injury,  or  operation. 

2.  The  symphysic :  Those  monstrosities  produced  by 
the  fusion  of  parts  from  disease,  injury,  or  operation. 

3.  The  ceasmic :  Those  monstrosities  in  which  a  cleft 
results  from  disease,  injury,  or  operation. 

4.  The  atresic :  Those  monstrosities  in  which  natural 
openings  are  occluded  from  disease,  injury,  or  operation. 

5.  The  hypergenetic  :  Those  monstrosities  in  which  cer- 
tain parts  are  inordinately  enlarged  by  disease. 

6.  The  ectopic :  Those  monstrosities  in  which  a  part  is 
displaced  by  disease  or  injury. 

16.  Functional  disorders  are  disturbances  of  the  func- 
tion of  an  apparatus  due  to  coincident  structural  change  in 
at  least  one  organ  of  this  or  sometimes  of  another  apparatus 
of  the  body.  Functional  disorders,  in  their  turn,  often  give 
rise  to  structural  disease. 

The  function  of  the  urinary  apparatus  may  be  disor- 


46 


dered  by  (1)  perversion,  (2)  deficiency,  (3)  suspension,  (4) 
excess,  (5)  diminution,  (6)  abolition. 

1.  Perversion  of  function  is  exemplified  by  glycosuria, 
albuminuria,  peptonuria,  cbyluria,  lipuria,  bsemoglobinuria, 
bsematuria,  pyuria,  pneumaturia. 

2.  Deficiency  of  function  is  exemplified  by  dysuresis 
(difiicult  urination),  ascheturesis  (irrepressible  urination), 
aconuresis  (involuntary  urination). 

3.  Suspension  of  function  is  exemplified  by  ischuria,  the 
consequences  of  which  are  often  ectasia  of  the  ureters,  blad- 
der, or  urethra  ;  cystitis  ;  rupture  of  the  urethra  and  extrava- 
sation of  urine  ;  urinary  fistulas  ;  or  rupture  of  the  bladder. 

4.  Excess  of  function  is  exemplified  by  hyperlithuria, 
polyuria,  sychnuresis  (frequent  urination). 

5.  Diminution  of  function  is  exemplified  by  oliguria. 

6.  Abolition  of  function  is  exemplified  by  anuria. 


47 


III. 

Summary  of  the  ^Etiology,  Sembiology,  Diagnosis, 
Prognosis,  Prophylaxis,  and  General  Therapeu- 
tics OF  Diseases  of  the  Urinary  Apparatus. 

The  results  of  an  examination  of  the  morbid  processes 
of  tlie  urinary  apparatus  having  been  stated  as  a  prelimi- 
nary step  to  the  study  of  special  affections  o£  particular 
organs,  further  inquiry  into  general  principles  is  necessary 
to  the  elucidation  of  the  aetiology,  semeiology,  diagnosis, 
prognosis,  prophylaxis,  and  therapeutics  of  these  affections. 
This  study  presupposes  a  fair  knowledge  of  anatomy, 
physiology,  and  pathology ;  otherwise  the  labor  would,  be 
vain. 

The  causes  of  diseases  of  the  urinary  apparatus  are  in- 
trinsic and  extrinsic. 

Examples  of  intrinsic  causes  are  disorders  of  the  nutri- 
tive apparatus,  the  gouty  diathesis,  malformations,  etc. 

Examples  of  extrinsic  causes  are  contagion,  parasitic 
invasion,  injuries,  the  lodgment  of  foreign  bodies,  and 
poisons. 

The  so-called  predisposing  causes  may  be  intrinsic  or 
extrinsic.  Among  these  causes  are  pre-existing  diseases  of 
organs  other  than  the  urinary,  such  as  the  lungs,  the  heart, 
or  the  liver,  intemperance,  filthy  habits,  etc.  Predisposition 
is  now  better  understood  by  the  broad  term  vulnerability. 
For  example,  any  disease  of  an  organ  which  causes  passive 


48 


congestion  in  another  organ  renders  this  organ  vulnerable, 
that  is  to  say,  more  easily  invaded  by  structural  disease. 
Intemperance  in  strong  drink  leads  to  diseases  of  the  liver 
as  well  as  of  the  urinary  ajoparatus.  The  drunkard,  already 
made  vulnerable  by  the  poison  alcohol,  is  often  so  much 
exposed  to  the  severity  of  the  weather  that  his  urinary  ap- 
paratus is  thereby  made  more  susceptible  to  disease.  He 
is  apt  to  be  careless  in  his  personal  habits  and  to  leave  his 
external  genital  organs  in  an  unwashed  and  filthy  state, 
which  renders  them  particularly  vulnerable.  The  same  in- 
dividual may  be  more  vulnerable  at  certain  times  than  at 
others,  and  many  circumstances  may  arise  to  increase  this 
vulnerability,  such  as  a  transitory  disorder  of  any  of  the 
functions.  He  is  likely  to  be  less  vulnerable  when  his 
bodily  functions  are  normal. 

Diseases  of  the  urinary  apparatus  may  arise  primarily, 
as,  for  instance',  a  phlegmasia,  a  neoplasraa,  a  blastoma,  a 
parasitic  invasion,  etc.  ;  may  be  consecutive  to  a  general 
dyscrasia,  or  to  disease  of  an  organ  of  the  same  or  of  an- 
other apparatus,  as  in  the  case  of  a  stenosis,  an  ectasis,  a 
concretion,  a  cyst,  a  functional  disturbance,  etc. ;  may  be 
the  outcome  of  injury  or  may  be  a  disorder  of  the  function 
of  the  apparatus  from  parasitic  invasion,  from  an  injury, 
from  a  teratism,  or  from  a  poison. 

The  symptoms  of  disease  of  the  urinary  apparatus  are 
subjective  and  objective.  The  varieties  of  subjective  symp- 
toms perceived  are  proportionate  to  the  degree  of  sensi- 
tiveness, intelligence,  and  power  of  observation  of  patients. 


49 


Young  children  perceive  pain  only,  and  give  it  expression 
by  an  outcry.  Stolid,  stupid,  ignorant,  degraded  men  are 
ordinarily  little  sensitive  to  pain,  and  unable  to  give  a  sat- 
isfactory account  of  their  condition.  Pusillanimous  adoles- 
cents are  unduly  demonstrative  of  pain,  even  when  it  is 
slight,  v?hile  courageous,  plucky  youths  when  in  great  suf- 
fering make  little  or  no  complaint,  but  the  facial  expression 
betrays  their  distress.  There  are  neurotic,  hysteroidal 
adults  who  suffer  more  from  apprehension  of  pain  than 
from  the  pain  that  exists,  or  that  may  be  inflicted  during 
a  physical  exploration.  The  management  of  these  algo- 
phobists  is  tedious,  diflicult,  harassing,  and  requires  tact, 
patience,  forbearance,  delicacy,  and  gentleness ;  but,  above 
all,  it  is  necessary  that  the  patient  have  the  greatest  confi- 
dence in  the  ability  and  integrity  of  the  physician.  Qnce 
convinced  that  he  is  not  to  be  injured,  he  becomes  docile 
and  submits  to  treatment  with  no  further  anxiety.  In 
some  cases  a  tumefaction,  if  not  painful  or  tender,  is  un- 
noticed by  the  patient  for  a  long  time.  Emaciation,  how- 
ever, seldom  escapes  the  patient's  attention.  Hfematuria, 
pyuria,  dysuresis,  aconuresis,  ischuria,  hyperlithuria,  sych- 
nuresis,  polyuria,  and  oliguria,  though  functional  disorders, 
rank  also  as  symptoms  which  are  perceivable  by  the  patient. 
Symptoms  are  often  so  inaccurately  detailed  by  patients  that 
the  physician  is  obliged  to  subject  them  to  the  most  rigid 
cross-examination  in  order  to  obtain  trustworthy  information. 
Objective  symptoms  are  perceived  by  the  physician  from 
answers  to  well-directed  questions,  from  ocular  and  manual 
inspection,  and  from  examination  of  excretions. 


50 


A  symptODi  denoting  invariably  the  existence  of  a  par- 
ticular disease  becomes  a  sign.  Sucb  symptoms  are  few, 
and  are  called  pathognomonic.  It  should  be  remembered 
that  the  symptom  belongs  to  the  senses  and  the  sign  to  the 
understanding.  The  patient  perceives  certain  symptoms, 
but  the  physician  alone  can  interpret  them  and  detect  a  sign. 
The  diagnostic  symptom,  that  manifestation  which  occurs 
more  frequently  in  connection  with  a  particular  disease  than 
with  other  diseases,  is  appreciable  only  by  the  physician. 

Prior  to  the  analysis  of  symptoms,  close  inquiry  should  be 
made  into  the  history  of  the  patient  and  the  history  of  his  dis- 
ease. His  constitutional  peculiarities,  inheritance  of  disease, 
previous  diseases,  occupation,  age,  and  habits,  and  the  pos- 
sible existence  of  organic  disease  other  than  urinary,  should 
form  the  basis  of  the  inquiry  into  the  history  of  the  patient. 

The  history  of  the  disease  for  which  the  patient  invokes 
assistance  is  the  next  step  in  the  inquiry.  The  date  of 
prodromic  symptoms  and  of  other  manifestations  is  noted, 
and  the  history  of  the  disease  traced  down  to  the  present. 
Then  ouestions  are  asked  relating  («)  to  the  seat,  character, 
degree,  and  duration  of  pain,  [b)  to  disordered  urination, 
(c)  to  the  amount  of  urine  passed  each  day,  and  (d)  to  the 
general  characters  of  the  urine. 

(a)  Pain  occurs  in  nearly  all  the  affections  of  the  urin- 
ary organs.  It  is  often  the  first  symptom  perceived,  and  it 
is  ordinarily  for  its  relief  that  the  patient  seeks  advice. 
Therefore  the  .physician  should  be  precise  in  ascertaining 
the  time  and  cii'cumstances  of  its  inception,  and  in  learning 


51 


its  seat  and  character  ;  whether  it  is  intermittent  or  con- 
tinuous, dull  or  acute,  aggravated  or  not  by  exercise,  in- 
tensified or  iiot  in  the  night ;  whether  it  occurs  before,  dur- 
ing, or  after  urination,  or  is  independent  of  urination.  Pain 
deeply  seated  in  the  lumbar  region  may  be  dull  or  acute. 

Dull  pain  in  this  region  indicates  a  lesion  of  slow  de- 
velopment— as,  for  example,  hydronephrosis  or  pyonephro- 
sis, chronic  pyelo-nephritis,  chronic  retention  of  urine  in 
the  bladder,  etc. 

Acute  pain  is  felt  in  the  lumbar  region  and  vicinity, 
and  also  along  the  course  of  the  ureter,  during  the  migra- 
tion of  a  urolith  or  from  any  cause  of  sudden  obstruction 
to  the  flow  of  urine  from  the  kidney  to  the  bladder.  The 
pain  is  often  radiated  to  the  other  abdominal  viscera,  and  is 
so  intense  as  to  require  the  free  use  of  anodyne  medicines. 

Persistent  dull  pain  in  the  hypogastric  region  may  be  ow- 
ing to  stagnation  of  urine  in  the  bladder,  or  to  chronic  cys- 
titis due  to  the  presence  of  a  tumor,  or  to  some  other  caus^. 

Acute  pain  in  the  hypogastric  region  is  evidence  of 
rapid  distention  of  the  bladder  by  the  urine,  or  of  irritation 
caused  by  the  presence  of  a  urolith  or  of  a  foreign  body, 
especially  in  the  bladders  of  young  subjects. 

Pain  at  the  extremity  of  the  penis  occurs  in  acute 
trachelocystitis,  in  prostatitis,  and  from  the  friction  of  a 
urolith  against  the  vesical  trigone,  particularly  during  sud- 
den movements  of  the  sufferer. 

Pain  in  the  sciatic  region,  often  extending  to  the  heel, 
commonly  the  left,  or  along  the  anterior  crural  nerves,  is 
suggestive  of  cystitis,  of  calculus,  of  prostatic  obstruction 


52 

or  of  urethral  stenosis,  as  well  as  of  coincident  rectal  irri- 
tation, tliese  several  lesions  giving  rise  also  to  many  other 
distant  neuroses. 

(b)  Disordered  urination  merits  the  close  attention 
of  the  diagnostician,  for  it  covers  a  wide  and  important 
field  of  inquiry. 

Urination  may  be  (1)  frequent,  (2)  irrepressible,  (3) 
difiicult,  (4)  painful,  (.5)  involuntary,  or  (6)  impossible.  (7) 
The  mode  of  urination  also  needs  to  be  observed.  The  jet 
may  be  irregular,  small,  feeble,  interrupted,  or  absent.  In 
the  last  case  the  urine  may  be  passed  guttatim,  may  slobber 
involuntarily,  or  may  cease  to  flow. 

1.  Frequent  urination  (sychnuresis)  is  common  to 
nearly  all  affections  of  the  urinary  apparatus  of  man  at  one 
stage  or  another  of  their  development.  It  may  be  asked, 
What  is  to  be  understood  by  frequent  urination  ?  The 
answer  is  that  no  absolute  rule  can  be  laid  as  to  what  pre- 
cise number  of  acts  of  urination  per  day  should  constitute 
undue  frequency.  In  the  same  healthy  individual  the  fre- 
quency of  urination  varies  according  to  the  season  of  the 
year,  the  character  and  amount  of  his  food  and  drink,  and 
of  exercise ;  in  fact,  all  deviations  from  his  habits  have 
their  influence  upon  the  quality  and  quantity  of  urine  se- 
creted, and  consequently  upon  the  frequency  of  its  expul- 
sion. There  are  adults  who  urinate  ordinarily  only  twice 
or  thrice  daily.  In  these  cases  five  or  six  acts  of  urination 
would  constitute  undue  frequency.  There  are  other  adults 
in  excellent  health  who  urinate  eight  or  nine  times  per  day. 


53 


In  these,  twelve  or  fifteen  acts  would  constitute  unduly  fre- 
quent urination.  Certain  animals  in  a  state  of  health — 
dogs,  for  instance — often  urinate  five  or  six  times  in  the 
course  of  half  an  hour,  though  they  often  repress  the  act 
for  several  hours.  Some  other  animals  habitually  hold 
their  urine  eight  or  ten  hours. 

Urination  is  unduly  frequent  in  cases  of  supersecretion 
(polyuria),  and  this  frequency  accords  with  the  quantity  of 
urine  secreted.  But  undue  frequency  of  urination  occurs 
in  many  cases  where  the  quantity  secreted  is  even  below 
the  normal  standard ;  in  such  circumstances  the  undue  fre- 
quency may  be  owing  to  the  irritating  properties  of  the 
urine,  to  trachelocystitis,  or  to  acute  or  chronic  cystitis, 
with  diminished  capacity  of  the  bladder.  Dyspeptic  and 
neurotic  subjects  free  from  any  lesion  of  the  urinary  or- 
gans urinate  with  undue  frequency  by  day  and  by  night. 
"  Brain-workers "  urinate  with  undue  frequency,  and  at 
each  act  expel  a  considerable  quantity  of  urine. 

Nocturnal  sychnuresis  is  worthy  of  special  considera- 
tion. An  apparently  healthy  elderly  man  may  urinate  once 
or  twice  during  the  first  three  hours  of  the  night,  but  if 
after  this  the  desire  to  urinate  recurs  two,  three,  or  four 
times,  there  is  good  ground  for  suspecting  prostatic  ob- 
struction. If,  then,  in  the  morning,  immediately  after 
urination,  a  catheter  be  introduced,  from  three  to  eight 
ounces  will  be  drawn,  showing  the  sychnuresis  to  be  due 
to  cystitis  from  stagnation  of  urine.  Nocturnal  sychnuresis, 
however,  occurs  often  in  calculous  subjects  free  from  pros- 
tatic obstruction. 


54 


Diurnal  syclinuresis  occurs  alike  in  cases  of  prostatic 
obstruction,  vesical  tuberculosis,  tumors,  stones,  and  lesions 
of  nervous  centers. 

2.  Irrepressible  urination  (asclieturesis),  often  confound- 
ed vpith  incontinence  of  urine,  occurs  in  cases  of  trachelo- 
cystitis  acconapanied  with  frequent  micturition.  It  differs 
from  involuntary  urination  in  one  essential  particular, 
i.  e.,  the  urine  escapes,  not  vk^ithout,  but  contrary  to,  voli- 
tion, in  spite  of  a  strong  effort  of  the  will  to  retain  it.  In 
the  case  of  involuntary  urination  the  will  is  not  exer- 
cised ;  no  effort  is  made  to  repress  the  urinary  flow.  When 
the  bladder  contracts  spasmodically  to  expel  only  a  small 
quantity  of  urine,  as  in  trachelocystitis,  whether  provoked 
by  a  stone  or  otherwise,  all  eff'ort  on  the  part  of  the  patient 
fails  to  restrain  the  flow  and  he  soils  his  garments,  or,  when 
this  urgent  need  to  urinate  awakens  him  from  sleep,  he  wets 
his  bed  before  he  can  reach  the  urinal.  Irrepressible  uri- 
nation occurs  occasionally  in  elderly  men  with  beginning 
prostatic  obstruction.  In  these  cases  it  is  caused  by  trache- 
locystitis. The  complication  of  polyuria  with  cystitis  is 
likewise  a  cause  of  irrepressible  urination.  It  also  occurs 
during  catheterism  of  neurotic  patients  and  of  young 
men  suffering  from  trachelocystitis,  the  urine  escaping, 
notwithstanding  the  strongest  wish  to  repress  it,  as  soon 
as  the  instrument  reaches  the  perineal  region  of  the 
urethra. 

3.  Difficult  urination  (dysuresis)  is  a  common  symptom 
of  disease  of  the  urinary  tract.  Although  it  is  ordinarily 
an  indication  of  material  obstacle,  such  as  urethral  stenosis. 


55 

contracture  of  the  vesical  neck,  prostatic  obstruction,  im- 
pacted calculous  matter,  or  the  presence  of  a  foreign  body, 
it  may  be  owing  to  other  causes,  such  as  lesions  of  nervous 
centers,  trachelocystitis,  diminished  or  impeded  vesical  con- 
traction, local  congestion,  etc.  The  act  of  micturition  may 
therefore  be  slow,  may  be  delayed,  or  difficult  at  the  begin- 
ning, at  the  end,  or  throughout. 

Slow  urination  occurs  alike  in  cases  of  prostatic  ob- 
struction, urethral  stenosis,  and  impeded  vesical  contraction 
from  connective-tissue  sclerosis,  and  may  therefore  indicate 
the  presence  of  either  or  of  all  these  pathic  conditions,  or 
may  be  owing  to  general  neurosis,  independent  of  any  local 
change  in  the  urinary  apparatus.  Slow  micturition  occurs 
also  in  case  of  overdistention  of  the  healthy  bladder  from 
mere  neglect  to  empty  the  viscus  at  the  proper  time — as, 
for  example,  during  alcoholic  intoxication. 

In  delayed  urination — detention  in  the  expulsion  of  the 
first  drops  of  urine — the  patient  is  obliged  to  wait  one  or 
even  two  minutes  before  the  urine  begins  to  flow.  The  jet, 
often  feeble  and  small,  is  interrupted  at  short  intervals,  the 
patient,  in  the  course  of  perhaps  half  an  hour,  making  sev- 
eral walking  excursions  in  his  room  before  the  bladder  is 
emptied.  This  occurs  during  the  morning  toilet,  and  indi- 
cates, in  young  and  middle-aged  men,  urethral  stenosis  with 
congestive  swelling  and  spasm  of  the  neck  of  the  bladder, 
and  in  elderly  men  may  be  a  symptom  of  beginning  prostatic 
obstruction.  In  many  cases,  however,  free  from  urethral, 
prostatic,  or  vesical  disease,  it  is  due  solely  to  congestive 
swellina"  at  the  urethro-vesical  orifice  incident  to  several 


56 


hours  of  recumbency  and  sleep,  and  intensified  by  disten- 
tion of  the  bladder.  After  free  exercise  during-  the  day, 
local  congestion  ceasing,  this  retardation  of  urination  is  no 
longer  experienced.  But  when  it  recurs  persistently  in 
elderly  men,  there  is  every  reason  to  suspect  beginning 
prostatic  obstruction.  Delayed  urination  occurs  often  in 
young  subjects  when  the  bladder  is  much  distended.  Neu- 
rotic patients  are  very  subject  to  this  delay.  Many  indi- 
viduals are  not  able  for  several  minutes,  or  are  never  able,  to 
urinate  in  the  presence  of  another  person  even  if  he  be  a 
physician  anxious  to  witness  the  act  of  urination  for  diag- 
nostic purposes. 

Difficult  urination,  when  constant  at  the  beginning  of 
the  act,  is  commonly  due  to  urethro-vesical  contracture  or 
to  prostatic  obstruction,  and  generally  lasts  throughout  the 
act,  but  is  not  necessarily  painful.  Toward  the  end  of  the 
act  of  urination  the  difficulty  is  usually  owing  to  the 
proximity  of  a  urolith  to  the  urethro-vesical  orifice ;  in 
such  a  case  there  is  much  pain  and  a  scalding  sensa- 
tion in  the  whole  urethral  canal.  In  case  of  a  urethral 
stenosis  the  difiiculty  is  proportionate  not  so  much  to  the 
degree  of  the  contraction  as  to  its  longitudinal  extent  and 
tortuosity. 

4.  Painful  urination  (algeinuresis)  is  another  symptom 
of  most  of  the  affections  of  the  urinary  apparatus.  It  is 
often  an  early,  and  for  some  time  the  only,  subjective  symp- 
tom of  grave  renal  disease — tuberculosis,  pyonephrosis,  cal- 
culous pyelitis,  etc. — the  patient  seeking  relief  of  the  symp- 
tom and  not  of  the  disease  to  which  it  is  due.    Any  disease 


57 


which  causes  marked  alterations  in  the  constituents  of  the 
urine  renders  that  urine  irritating  and  otherwise  obnoxious 
to  the  bladder  and  to  the  urethra ;  in  other  words,  causes, 
in  the  bladder  and  urethra,  more  or  less  pain  during  its 
emission.  Hyperlithuria,  excessive  pyuria,  inordinate  alka- 
linity of  the  urine,  cause  much  burning  pain  in  healthy 
urethrse  during  the  act  of  urination. 

5.  Involuntary  urination  (aconuresis)  most  frequently 
indicates  overdistention  of  the  bladder,  particularly  in 
elderly  men  with  prostatic  obstruction ;  but  it  occurs  also 
in  cases  of  overdistention  of  the  bladder,  at  any  age,  from 
urethral  obstruction  by  a  stenosis  or  by  the  lodgment  of  a 
urolith.  Involuntary  urination  is  likewise  an  indication 
of  imperfect  closure  of  the  urethro-vesical  orifice  in  elderly 
men  affected  with  multiple  tumors  at  the  base  of  the  pros- 
tate ;  these  are  among  the  cases  styled  true  incontinence  of 
urine.  Other  examples  of  true  incontinence  of  urine  are 
those  due  to  absolute  paralysis  of  the  bladder  or  to  mal- 
formations. 

The  nocturnal  involuntary  micturition  of  children  is  not 
ordinarily  incontmence  of  urine,  for  the  great  quantity 
passed  each  time  indicates  distention  of  the  bladder.  The 
diurnal  sychnuresis  and  involuntary  urination  of  these 
little  ones  give  evidence  of  polyuria  which  is  the  exciting- 
cause.  In  some  cases  there  is  irrepressible  rather  than  in- 
voluntary urination.  In  none  of  these  cases  is  there  in- 
continence of  urine,  for  the  bladder  can  and  does  contain  a 
considerable  quantity  of  urine  before  the  need  comes  for  its 
expulsion. 


58 

6.  Impossible  ut'ination — retention  of  urine  (ischuria) — 
is  ordinarily  the  outcome  of  a  material  obstacle  at  the  ure- 
thro-vesical  orifice  or  in  the  urethra.  In  the  first  case,  from 
spasmodic  or  from  permanent  contracture,  from  prostatic 
obstruction,  or  from  the  impaction  of  a  urolith.  In  the  sec- 
ond case,  from  stenosis,  from  the  impaction  of  a  urolith  or 
of  an  extraneous  body,  or  from  an  injury. 

7.  The  manner  in  which  they  urinate  can  ordinarily  be 
described  by  intelligent  patients,  but,  as  a  general  rule,  it  is 
better  that  the  physician  trust  to  his  own  senses  in  order 
that  he  may  properly  value  and  interpret  the  character  of 
urination  in  particular  cases. 

The  propulsion  of  the  urine  is  subject  to  several  modifi- 
cations, in  accordance  with  certain  local  conditions  of  the 
urethra,  prostate,  and  bladder. 

Gradual  diminution  in  size  of  the  stream  of  urine  dur- 
ing a  period  of  months  or  years  points  to  the  existence  of 
urethral  stenosis. 

An  inordinately  small  stream  of  urine  may  indicate 
urethro-vesical  contracture,  urethral  stenosis,  or  impaction 
of  calculous  matter  in  the  urethra. 

The  passage  of  urine  guttatim  portends  retention  of 
urine  from  urethral  stenosis. 

A  small,  slow,  feeble,  perpendicular  stream,  interrupted 
by  a  succession  of  drops,  is  indicative  of  prostatic  obstruc- 
tion. 

The  slobbering  of  urine  is  a  sign  of  overflow,  and  con- 
sequently of  incomplete  retention  of  urine  with  overdisten- 
tion  of  the  bladder. 


59 

Constant  flow  of  urine  from  an  undistended  bladder  is  a 
sign  of  incontinence  of  urine. 

Small,  frequent,  spasmodic  jets  of  urine  suggest  acute 
trachelocystitis. 

(c)  Inquiry  as  to  the  amount  of  urine  passed  eacli 
day  is  of  no  little  importance,  for  very  considerable  varia- 
tions occur  in  primary  as  well  as  in  secondary  renal  affec- 
tions. Thus,  for  instance,  a  persistent  excess  above  the 
amount  of  urine  voided  each  day  may  indicate  chronic  in- 
terstitial nephritis  with  sclerosis  (contracted  kidney),  which 
may  be  the  outcome  of  modifications  of  arterial  tension  from 
cardiac  disease,  or  may  indicate  degeneration  of  the  kid- 
neys from  urethral  and  vesical  disease.  The  increase  of  se- 
cretion (polyuria)  varies  from  sixty  to  two  hundred  ounces 
daily,  or  even  to  a  greater  extent.  Polyuria  may  be  compli- 
cated with  glycosuria  dependent  upon  errors  in  the  nutritive 
function  or  upon  cerebral  disease. 

Diminution  of  secretion  (oliguria)  may  follow  polyuria, 
or  may  result  from  acute  nephritis.  When  it  occurs  during 
or  after  an  attack  of  urinary  fever  it  is  ominous  and  por- 
tends anuria  and  death. 

id)  The  physical  characters  and  chemical  properties 
of  abnormal  urine  form  the  last  part  of  the  inquiry  into  the 
history  of  the  disease,  and  comprise  an  examination  of  the 
significance  of  variations  in  the  limpidity,  turbidity,  micro- 
scopical appearance,  color,  and  chemical  reactions  of  this 
urine. 


60 


Urine  may  be  Iwijnd  when  voided,  it  may  retain  its  lim- 
pidity after  cooling,  or  may  become  turbid  in  a  greater  or 
less  degree.  After  standing  a  sbort  time,  limpid  urine  often 
yields  a  reddish  deposit  resembling  ground  Cayenne  pepper, 
which,  on  microscopical  examination,  proves  to  be  uric  acid. 
When  clear  urine  becomes  turbid  on  cooling  and  is  cleared 
by  the  application  of  heat,  and,  when  it  is  again  cooled,  a 
precipitate  once  more  occurs,  it  is  owing  to  the  presence  of 
urates  which  may  be  identified  by  microscopical  examina- 
tion. Clear  urine  sometimes  yields  a  scanty  deposit  con- 
sisting of  oxalate  of  lime  or  of  casts  of  the  uriniferous 
tubes,  free  epithelium,  etc.,  indicating  in  the  second  case 
renal  disease. 

The  urine  may  be  markedly  turbid,  resembling  pea-soup, 
when  passed.  This  is  owing  to  the  presence  of  a  great 
amount  of  urates.  A  very  abundant  purulent  sediment  in- 
dicates cystitis,  pyelitis,  or  both.  When  this  sediment 
consists  of  creamy  pus  the  presumption  is  that  the  pus 
comes  from  the  pelvis  of  the  kidney,  but  when  the  pus 
is  slimy  and  contains  phosphatic  crystals,  it  is  presumably 
vesical. 

The  color  of  the  urine  should  be  carefully  noted  for  di- 
agnostic purposes,  and  its  significance  will  be  fully  realized 
by  studying  the  accompanying  table,  illustrative  of  the  tints 
of  urine,  copied  from  Thudicum's  excellent  work  on  the 
pathology  of  the  urine  : 


61 


Table  Illustrative  of  the  Tints  of  Urine  (Thudicum). 


Substance  to 

which  the 
color  is  due. 


Pale  yel 
low  hue  to 
straw- 
yellow 


Lemon- 
yellow. 


Amber 
color. 


Yellowish- 
green. 


Greenish 
to  grass- 
green. 


Reddish- 
yellow  to 
red. 


Red  to 
brown 

and  deep  j   of  haema- 
brown.    !    toxylon, 

I  chimaphiia. 

I      coffee. 

Senna. 


Shortest  chemical  test. 


Uraematin, 
smallest 
amount. 


Uroxan-     Drop  twenty  to  forty 
thin.  drops  of  urine  in- 

to two  or  three 
drachms  of  fum- 
ing hydrochloric 
acid.  Reddish  vio- 
let color  to  blue  is 
produced. 
Ursematin.  Add  to  boiling  urine 
one  fourth  of  its 
bulk  of  hydro- 
chloric acid.  Pink 
or  purple  color 
produced. 


Pigment 
of  bile. 


Mixture  of 
urosan- 
thin  with 
any  of  the 
blue  pig- 
ments. 
Ursematin, 
large 
amount. 


Coloring 
principles 


Let  a  drop  of  nitric 
acid  fall  in  the 
center  of  a  thin 
layer  of  urine  on  a 
white  plate,  when 
a  transient  play  of 
colors  in  rings  of 
pink,  violet,  and 
green  is  produced. 

Several  tests  of  these 
substances. 


Hydrochloric  acid. 


Coffeurine  may  be 
known  from  the 
characteristic  odor. 


Mineralacidschange 
the  dark  red  or 
brownish  color  of 
this  and  rhein  in- 
to light  yellow. 


Concomitant 

characters  of 

urine. 


Reaction  most- 
ly neutral.  Lit- 
tle urea  and 
solids  (except 
diabetes,  when 

sugar  aug- 
ments solids). 
Deficiency  of 
uraematin. 


Mostly  normal. 


Very  acid. 


Alkaline,  de- 
composed ; 
much  carbon- 
ate of  am- 
monia. 

Reaction  acid. 
Large  amount 
of  solids,  par- 
ticularly urea. 

Subject  to 
accident. 


Pathological  indications. 


Much  water  drunk. 
Ansemia,  chloro- 
sis, diabetes.    Ex- 
cludes febrile  and 
acute  diseases. 


Occurs  in  cholera 
and  spinal  disease. 


Being  the  urine  of 
health,  this  color 
excludes  all  dis- 
eases of  which 
either  pale  or  very 
high-colored  urine 

IS  a  symptom. 
Obstruction  to  the 

passage  of  bile 

from  the  liver  and 

gall-bladder  into 

the  intestines ; 

presence  of  the 

constituents  of  bil  e 

in  the  blood. 

Has  occurred  in 

cystitis  and 
Brisrht's  disease. 


Little  liquid  taken. 
Excess  of  nutri- 
tiv'e,  nitrogenous 
matter  ;  free  per- 
spiration.   Fever. 
The  ingestion  into 
the  stomach  of 
haematoxylon, 
chimaphiia,  senna, 
rhubarb,  and  cof- 
fee, or  their  ex- 
tracts and  infu- 
sions. 


62 


Substance  to 

Concomitant 

Color. 

which  the 
color  is  due. 

Shortest  chemical  test. 

characters  of 
urine. 

Pathological  indications. 

Rbubarb. 

Liquor       ammonia; 

converts  the  dark 

orange  or   brown 

into  crimson. 

Pigment 

Nitric  acid. 

of  bile. 

Pink  or 

Purpurin 

Is  precipitated  with 

Urine  always 

Indicates  frequent- 

rosy. 

(uroery- 

deposits  of  urate  j  acid,  making 

ly  the  presence  of 

thrin). 

of   ammonia  and    mostly  a  de- 

serious  lesions. 

soda,  and  may  bei  posit  of  urates 

Rest  problematical. 

combined       with 

on  cooling. 

them  artificially. 

Red  to 

Urrhodin. 

Is     a    product     of 
decomposition   of 

purple. 

urosanthin,      and 

with     blue      pig- 

ments makes  the 

urine  violet. 

Blue. 

Cyanurin 

Let    urine    decom- 

Ammoniacal 

Observed  in  cysti- 

(uroglau- 

pose,  or  add  con- 

decomposition 
in  the  bladder. 

tis  and  Bright's 

cin)  ; 

centrated  ]SIO=,  or 

disease.    Cyanu- 

indigo. 

HCl.    Pigment  is! 

rin  sometimes 

destroyed  oi-  evap- 

discharged during 

oration  of   urine. 

apparent  health. 

Concentrated  SO3, 

In  that  case  the 

J  to  J  volume,  pro- 

urine is  of  amber- 

duces  a  test  likel 

color,  and  the  pig- 

that of  Pettenko- 

ment  only  appears 

fer  for  bile.  Indigo 

on  addition  of 

not    afEected     by 

acids. 

boiling  with  HCl. 

Violet. 

Mixture  of 
the  red  and 

Those  of  the  sepa- 
rate substances. 

blue  pig- 

ments, nor- 

mal and 

abnormal. 

! 

Reddish- 

Hsematin. 

Coagulable  by  heat 

Typhus.    Breath 
ihg  of  arseniureted 

brown  to 

(sometimes) ;  pre- 

brown, 

cipitated  by  acids 

hydrogen. 

porter- 

in flocculi. 

like. 

Blackisb- 

Hsematin, 
and  blood 

Sometimes    as    de- 
posit in  clear  or- 

The ingestion  of 
carbolic  acid  into 

gi-ay,black 

like  ink. 

becomes 

black  in 
putridurine. 

Tar  and 
creasote,  or 

carbolic 
acid. 

dinary  urme. 

the  blood,  througli 

the  stomach  or 

skin. 

Respecting  tlie  chemical  reactions  of   abnormal    urine 
only  little  need  now  be  said. 


63 


Urine  of  inordinately  high  acid  reaction  is  irritating  to 
the  mucous  membrane  of  the  urinary  tract. 

Urine  of  alkahne  reaction  is  also  somewhat  irritating, 
hut  strongly  ammoniacal  urine  causes  the  greatest  distress 
in  the  bladder  and  urethra. 

Urine  containing  uric  acid  in  excess  is  highly  irritating, 
and  even  causes  cystitis  and  urethritis.  Oxalate  of  calcium 
in  abundance  of  octahedral  crystals  produces  the  same 
effects. 

Urine  containing  amorphous  phosphate  of  calcium  is 
ordinarily  acid,  and  causes  little,  if  any,  irritation. 

Alkaline,  slimy  urine  indicates  the  presence  of  triple 
ammonio-magnesian  phosphates. 

A  marked  deficiency  of  urea  in  the  urine  is  to  be  re- 
garded as  a  serious  objective  symptom,  while  a  decided  ex- 
cess of  urea  indicates  great  expenditure  of  energy  or  much 
waste  of  tissue  from  disease,  or  the  excessive  ingestion  of 
nitrogenous  food  and  insufficient  bodily  exercise. 

When  urine  containing  an  abundance  of  sugar  is  re- 
tained a  few  hours  in  the  bladder,  fermentation  soon  begins, 
and  it  is  not  long  before  cystitis  is  developed  ;  the  urine  then 
voided  being  very  foetid,  turbid,  slimy,  purulent,  phosphatic, 
and  swarming  with  microzymes.  At  the  time  of  its  emis- 
sion a  considerable  quantity  of  gas,  resulting  from  this  bac- 
terial fermentation,  escapes  in  large  bubbles,  often  to  the 
dismay  of  the  patient,  who  suspects  intestinal  implication. 

Albumin  in  the  urine  indicates  renal  or  vesical  disease, 
the  presence  of  pus  or  of  blood,  or,  in  health,  the  ingestion 
of  large  quantities  of  albuminous  food — such  as  eggs,  etc. 


64 


Dr.  Carroll  mentioris  the  case  of  a  patient  whose  urine  was 
albuminous  during  the  period  of  thirty  years,  and  who  died 
at  the  age  of  sixty. 


Substances  which  exist  in  Normal 
when  in 

Urea. 
Uric  acid. 

C  sodium. 

I  ammonium. 
I 
Urates  of  -{  potassium. 

calcium. 

magnesium. 

i  sodium, 
potassium, 
calcium. 


Lactates  of 


Chlorides  of 


sodium. 

potassium. 

calcium. 
/  sodium. 
•j  ammonium. 
'  potassium. 


Urine,  but   constitute  Abnormities 
Excess. 
Creatin. 
Creatinin. 
Oxalate  of  calcium. 

i  sodium, 
potassium, 
calcium, 
f  sodium. 


Phosphates  of  -{ 


calcium. 
1^  ammonium. 
Ammonio-magnesian  phosphates. 
Silicic  acid. 

Margarin,  olein,  and  other  fats. 
Urochrome. 
Vesical  mucus. 


Substances  which  do  not  exist  in  Normal  Urine,  and  the  Presence  of 

which  constitutes  Abnormities. 
Sugar. 
Calcium  carbonate. 


Cjstin. 

Pus. 

Chyle. 

Blood. 

Hcematin. 

Htemoglobin. 

Albumin. 

Bile. 

Leucine. 

Tyrosine. 

Hypoxanthin. 


Purpurin. 

Spermatozoa. 

Casts  of  uriniferous  tubes. 

Cancer  cells. 

Entozoa. 

Tubercle  bacilli  and   other  micro 

organisms. 
Phenic  acid. 
Iodine 
Arsenic. 
Antimony. 
Lead. 
Copper  and  other  poisons. 


65 


Diagnosis,  the  discrimination  of  diseases  and  the  dis- 
covery of  their  character  and  seat,  is  effected  (1)  by  analyz- 
ing their  symptoms,  (2)  by  physical  exploration,  (3)  by  re- 
course to  chemical  and  microscopical  examination  of  excre- 
tions or  of  portions  of  tissue,  and  (4)  by  a  synthetic  mental 
process,  summarizing  the  different  kinds  of  information 
obtained  and  deducing  the  sign  or  indication  of  the  presence 
of  a  particular  disease. 

It  often  happens  that  the  diagnosis  of  a  disease  of  the 
urinary  apparatus  is  extremely  difficult  owing  to  most  of  its 
symptoms  being  common  to  several  other  diseases  of  this 
apparatus.  In  such  a  case,  as  some  of  the  symptoms  are 
not  percejDtible  in  all  the  diseases  in  question,  these  diseases 
are  one  after  another  eliminated  from  consideration  until 
all  but  tv70  are  excluded,  when  may  be  employed  with  ad- 
vantage the  differential  method  of  diagnosis,  which  consists 
in  the  close  comparison  and  proper  interpretation  of  the 
dominant  symptoms,  and  of  the  results  of  the  accessory 
means  that  may  have  been  employed. 

Accurate  diagnosis  is  essential  to  rational  therapeusis 
and  to  correct  prognosis. 

The  PRoajfOSis  of  a  disease  of  the  urinary  apparatus — 
the  foretelling  of  its  course  and  termination — requires  a 
thorough  study  of  its  nature,  a  mature  knowledge  of  its 
ordinary  duration,  a  searching  inquiry  into  the  effect  of 
previous  treatment,  and  a  careful  observation  of  the  general 
condition  of  the  sufferer.  This  also  serves  to  establish  the 
indications  of  future  treatment. 


66 

To  the  patient  and  to  Ms  near  relations  and  friends 
prognosis  is  all-important.  They  desire  and  have  the  right 
to  know  if  he  is  likely  to  recover ;  if  so,  when ;  if  not, 
what  will.be  the  probable  duration  of  life,  what  the  extent 
of  his  suffering,  if  it  can  be  alleviated,  and,  finally,  if  a 
cutting  operation  is  indicated  ;  if  not,  why  it  is  contra- 
indicated. 

The  prognosis  is  unfavorable  in  cases  of  advanced  renal 
disease  complicating  urethral  stenosis,  prostatic  obstruction, 
and  stone  in,  and  tumors  of,  the  bladder  of  long  standing. 
In  such  cases  cutting  operations  are  clearly  contra-indicated 
as  most  likely  to  shorten  the  patient's  life,  which  judicious 
palliation  renders  endurable. 

In  malignant  disease  of  an}^  of  the  organs  of  the  urinary 
apparatus,  with  contamination  of  the  lymphatics,  the  prog- 
nosis is  unfavorable,  and  cutting  operations  are  contra- 
indicated.  Palliative  treatment  should,  however,  not  be 
neglected. 

In  advanced  tuberculosis  of  the  urinary  apparatus  the 
prognosis  is  unfavorable,  and  palliative  measures  only  are 
indicated. 

Close  attention  to  prognosis  tends  to  prevent  recourse  to 
painful  and  dangerous  therapeutic  means,  or  to  cutting 
operations,  which  seldom,  if  ever,  relieve  suffering  while 
they  rapidly  lead  to  a  fatal  issue. 

The  prophylaxis  of  several  diseases  of  the  urinary  ap- 
paratus may  be  effected  by  avoidance  of  contagion,  by  ab- 
stention from  excesses,  by  due  observance  of  the  rules  of 


67 


hygiene,  by  the  use  of  prophylactic  medicinal  agents,  or  by 
early  surgical  interference. 

The  formation  of  calculous  concretions  may  be  pre- 
vented by  timely  general  treatment  of  hyperlithuria,  by 
frequently  withdrawing  stagnant  alkaline  urine  from  the 
bladder  and  cleansing  it,  or  by  the  early  removal  of  foreign 
bodies. 

Ureteritis,  ectasia  of  the  ureters,  pyonephrosis,  and 
pyelonephritis  may  all  be  prevented,  in  cases  of  urethral 
stenosis  and  of  prostatic  obstruction,  by  early  attention  to 
the  contracted  urethra  and  to  the  bladder. 

The  complete  cure  of  urethritis  is  often  preventive  of 
stenosis  of  the  urethra. 

The  prompt  resort  to  external  perineal  urethrotomy,  fol- 
lowed by  dilating  catheterism  in  transverse  wounds  of  the 
perineal  portion  of  the  urethra,  is  preventive  of  those  trau- 
matic stenoses  which  are  so  fatal  to  sufferers. 

The  judicious  use  of  quinine  during  the  surgical  treat- 
ment of  diseases  of  the  urinary  apparatus  is  often  prevent- 
ive of  the  intercurrence  of  rigors,  and,  when  these  have 
already  begun,  palliates  them  and  often  prevents  their  re- 
currence. The  administration  of  minim  doses  of  aconite 
tincture  is  of  great  value  in  the  febrile  reaction  which  so 
frequently  occurs  after  operations,  or  in  diseases  of  the  uri- 
nary organs,  even  in  urethritis. 

The  general  therapeusis  of  diseases  of  the  urinary 
apparatus  implies  a  good  understanding  of  the  principles  of 
action,  indication,  and  application  of  means  of  palliation 


68 


and  of  cure,  is  an  indispensable  prerequisite  to  the  efficient 
management  of  particular  diseases  of  the  organs  of  this 
apparatus,  and  is  deduced  from  general  pathology,  from  a 
practical  knowledge  of  the  effects  of  medicinal  agents,  and 
from  a  study  of  the  results  of  surgical  processes.  Only  gen- 
eral principles  are  thereby  established,  no  fixed  rules  can 
be  rational,  for  many  circumstances  arise  that  lead  the 
physician  to  modify  his  treatment  even  of  the  same  patient, 
and  he  has  no  other  guides  than  are  afforded  by  mature  ex- 
perience, quick  perception,  sound  judgment,  a  cool  head, 
and  a  steady  hand.  Too  much  haste  to  do  for  a  patient  is 
often  productive  of  much  harm.  In  certain  difficult,  doubt- 
ful cases,  how  much  better  it  is  to  do  nothing  than  to  do 
the  wrong  thing,  or  to  do  the  right  thing  at  the  wrong  time 
or  in  a  way  that  is  almost  certain  to  be  injurious  and  per- 
haps fatal  to  the  sufferer  !  In  these  circumstances,  a  little 
delay,  sufficient  to  bring  into  play  the  reasoning  faculties,  is 
most  wholesome  and  enables  the  physician  to  exercise  his 
skill  greatly  to  the  advantage  of  the  patient. 

Among  the  inexperienced  there  is  a  strong  tendency  to 
overdo  the  right  thing,  the  result  being  that  the  sick  man, 
thus  tormented  by  meddlesome  medicinal  and  manual  medi- 
cation, becomes  fretful,  his  body  temperature  rises,  his 
pulse  is  quick  and  frequent,  he  is  sleepless,  and  his  appetite 
vanishes.  These  phenomena  are  not  properly  interpreted  ; 
a  consultation  is  finally  called,  and  the  advice  is,  too  much 
of  the  right  thing  has  been  done ;  cease  all  interference  and 
let  the  patient  get  well. 

A  young  surgeon,  filled  with  enthusiasm,  eager  for  glory 


69 


anxious  to  do  his  whole  duty,  well  informed  in  all  the  mod- 
ern devices,  has  just  taken  charge  of  his  first  case  of  nar- 
row stricture  in  the  phallic  region  of  the  urethra.  He  de- 
cides to  perform  internal  urethrotomy  and  subjects  his 
patient  to  the  most  rigid  preparatory  treatment.  He  steril- 
izes the  urine  with  free  doses  of  oil  of  gaultheria,  which  are 
to  be  continued  throughout  the  after-treatment,  administers 
quinine  without  stint  as  a  prophylactic  of  urethral  fever, 
disinfects  his  instruments,  injects  a  good  quantity  of  a  four- 
per-cent.  cocaine  solution,  executes  the  operation,  success- 
fully arrests  the  consequent  haemorrhage,  resorts  to  dilating 
catheterism  once  each  day,  and  causes  the  urethra  to  be  in- 
jected every  two  hours  night  and  day  for  a  week  with  a 
l-to-5,000  sublimate  solution,  adding  thereto  a  liberal 
amount  of  boric  acid  and  peroxide  of  hydrogen.  At  the 
expiration  of  this  time  he  is  alarmed  to  find  his  patient  so 
ill,  with  loss  of  appetite  and  sleep,  with  fever  and  the  ac- 
companying fretfulness,  and  with  an  extremely  sensitive 
and  irritable  urethra,  that  he  requests  a  consultation.  The 
consulting  physician  listens  patiently  to  a  detailed  recital 
of  the  whole  case,  and,  taking  the  attending  surgeon  to  an 
adjoining  room,  says  he  is  greatly  surprised  to  find  the  man 
alive  after  being  subjected  to  the  torture  of  so  much  un- 
necessary medication,  and  advises  its  immediate  cessation. 
From  that  moment  the  patient  begins  to  improve,  and  is 
allowed  to  get  well  by  being  catheterized  only  once  a  week. 
This  is  no  exaggeration,  but  a  true  picture  of  a  not  infre- 
quent occurrence. 

It  is  almost  needless  to  say  that  diseases  are  not  cured 


70 


by  medicines  or  by  surgical  operations.  In  the  first  case, 
drugs  are  given  to  remove  the  cause  by  destroying  its  mor- 
bific agency,  whatever  it  may  be,  and  in  the  second  case  an 
operation  is  performed  to  remove  an  obstruction,  a  growth, 
or  a  foreign  substance,  or  to  relieve  a  distended  bladder, 
which  may  be  disturbing  the  bodily  functions ;  Nature 
effects  the  cure. 

The  general  principles  of  treatment  of  diseases  of  the 
urinary  apparatus  relate  to  means  by  which  a  disease  is 
cured  or  palliated  and  by  which  the  individual  may  be 
placed  in  the  most  favorable  condition  to  resist  its  effects ; 
therefore  quite  as  much  attention  should  be  bestowed  upon 
the  treatment  of  the  patient  as  upon  the  management  of 
his  disease.  Suitable  hygienic  precautions,  a  wholesome 
alimentation,  the  judicious  use  of  stimulants,  and  such 
other  analeptic  measures  as  may  be  indicated,  form  the 
basis  of  the  treatment  of  the  patient.  The  disease  may  re- 
quire medicinal  as  well  as  mechanical  means.  For  instance, 
to  relieve  pain,  to  eradicate  a  poison,  or  to  destroy  an  in- 
fective agent,  drugs  known  by  experience  to  possess  hyp- 
notic, neutralizing,  or  specific  properties  are  indicated — as 
anodynes  to  relieve  pain,  sterilizing  agents  in  urethritis, 
and  mercury  in  syphilis.  Operations,  such  as  catheterism 
to  relieve  retention  of  urine ;  lithotomy  or  lithotrity  for  the 
removal  of  stone  from  the  kidney,  bladder,  or  urethra  ;  dila- 
tation, divulsion,  or  urethrotomy  for  the  cure  of  stricture  ; 
nephrotomy  to  relieve  pyonephrosis  ;  nephrectomy  for  cer- 
tain diseased  kidneys ;  and  cystotomy  for  the  excision  of 
vesical  tumors.     An  accurate  diagnosis,  a  sound  judgment 


n 


of  the  indications  of  special  processes,  and  a  masterly 
operative  skill  are  absolutely  necessary  to  tlie  successful 
management  of  a  particular  disease. 

The  greatest  caution  should  be  exercised  in  prescribing 
some  of  the  medicinal  agents  required  in  the  treatment  of 
affections  of  the  urinary  organs.  Among  these  opium 
should  be  particularly  mentioned  for  two  among  many 
good  reasons :  First,  because  of  its  known  property  to 
lessen  the  urinary  secretion,  which  is  sometimes  a  most 
dangerous  consequence,  and,  second,  because  long  suf- 
ferers from  gravel,  stone,  and  other  painful  affections 
are  apt  to  acquire  the  "  opium  habit,"  beginning  with 
small  doses  and  gradually  increasing  the  quantity  until 
the  habit  is  fixed.  Valuable  as  is  this  drug,  it  should 
rarely  be  used  and  given  only  in  case  of  the  most  urgent 
necessity. 

Stimulating  diuretics  are  also  dangerous  and  should 
therefore  be  avoided.  Mild  diluents  and  diaphoretics 
should  be  employed  in  their  stead. 

A  few  words  may  not  be  out  of  place  concerning  cer- 
tain questions  asked  by  junior  members  of  the  profession, 
to  wit : 

1.  What  is  the  duty  of  the  surgeon  when  it  is  diflicult  or 
not  possible  to  determine  the  character  and  extent  of  an 
operation  which  may  be  indicated  by  a  pathic  condition  the 
nature  of  which  can  not  be  ascertained  until  the  parts  are 
exposed  to  view  by  the  knife  ? 

2.  Is  the   surgeon  justified,   immediately  after  an  ex- 


72 

ploratory  operation,  to  proceed  to  the  final  operation  against 
the  consent  of  the  patient ;  that  is  to  say,  if  the  patient 
had  refused  to  submit  to  anything  more  than  an  exploratory 
operation  ? 

3.  Is  the  surgeon  justified,  without  the  consent  of  the 
patient,  to  proceed  to  the  final  operation  at  the  conclusion 
of  the  exploratory  operation  while  the  patient  is  under  the 
influence  of  the  anaesthetic  agent  ? 

These  questions  may  be  answered  as  follows : 

1.  The  duty  of  the  surgeon  is  to  employ  all  the  means 
of  diagnosis  at  his  command  before  proposing  an  explora- 
tion which  involves  the  use  of  the  knife,  and,  failing,  his 
further  duty,  if  there  be  time,  is  to  submit  the  case  to  an- 
other surgeon  for  his  diagnosis,  opinion,  and  advice.  If 
then  an  exploratory  operation  be  advisable,  its  nature  and 
also  the  character  and  extent  of  the  operation  likely  to  be 
indicated  by  the  exploration  should  be  fully  explained  to 
the  patient. 

2.  If  the  patient  refuse  to  submit  to  anything  more  than 
the  exploratory  operation,  the  surgeon  is  not  justified  to 
proceed  beyond  the  exploratory  operation. 

3.  Under  no  circumstances  is  the  surgeon  justified,  with- 
out the  consent  of  the  patient,  to  proceed  further  than  the 
exploratory  operation. 

What  is  then  to  be  done,  asks  the  junior  surgeon, 
if  the  wound  inflicted  in  the  exploration  is  such  as  to 
be  remediable  only  by  the  final  operation,  or  such  that 
the  patient  may  die  unless  the  final  operation  be  at  once 
performed  ? 


73 


The  answer  to  this  question  is  that  the  experienced  sur- 
geon is  not  likely  to  place  himself  in  such  a  position,  nor 
to  entertain  the  thought  of  undertaking  an  exploration 
without  having  had  a  distinct  understanding  with  the  pa- 
tient that  he  must  trust  to  the  judgment  of  the  operator  as 
to  what  the  exploration  may  indicate,  and  give  his  full  con- 
sent to  the  performance  of  the  necessary  operation.  If  the 
patient  refuse  to  enter  into  this  agreement,  the  surgeon  is 
justified  in  declining  to  operate  or  even  to  continue  in  charge 
of  the  case. 


74 


Section  l\.— SPECIAL    CONSIDERATIONS. 

IV. 

Insteestitial  Nepheitis,  Pyelonepheitis,  and  Peeinephei- 
Tis ;  THEiE  Natuee,  Stmptoms,  Peogress,  Diagnosis,  and 
Treatment. 

The  phlegmasic,  being  the  most  common  of  the  affec- 
tions of  the  urinary  organs,  should  be  first  examined.  The 
kidneys,  ureters,  bladder,  prostate,  bulbo-urethral  glands, 
and  urethra,  are  all  subject  to  phlegmasia  ^vith  varying  de- 
grees of  frequency.  These  affections  will  be  discussed  in 
the  order  in  which  the  several  urinary  organs  have  just  been 
enumerated,  beginning  with  nephritis. 

Nephritis — phlegmasia  of  the  kidney — may  be  second- 
ary to  some  affection  of  organs  other  than  the  urinary,  or 
to  some  affection  of  the  lower  urinary  organs,  or  may  occur 
as  a  primary  disease.  The  substance  of  the  kidney  only 
may  be  affected — nephritis ;  or  the  enveloping  tissue  of  the 
kidney  may  alone  be  affected — perinephritis.  Nephritis 
may  extend  to  the  enveloping  tissue  and  cause  a  secondary 
perinephritis,  and  a  primary  perinephritis  may  extend  into 
the  kidney  substance  and  cause  a  secondary  nephritis. 

Interstitial  Nephritis, — The  species  of  nephritis  that 
particularly  concern  the  surgeon  are  interstitial  nephritis. 


75 


pyelonephritis,  and  perinephritis.  By  interstitial  nephritis 
is  meant  a  phlegmasia  of  the  intertubular  substance  of  the 
kidney  ;  by  pyelonephritis,  improperly  termed  surgical  kid- 
ney, is  meant  a  phlegmasia  involving  the  mucous  membrane 
of  the  renal  pelvis  and  the  intertubular  substance  of  the 
kidney ;  and  by  perinephritis  is  meant  a  phlegmasia  affect- 
ing the  layer  of  connective  and  adipose  tissue  that  invests 
the  kidney.  In  these  cases  the  phlegmasia  may  be  super- 
acute,  acute,  subacute,  or  chronic.  It  may  be  descending  or 
ascending. 

Descending  nephritis  is  ordinarily  secondary  to  disease 
of  some  organ  foreign  to  the  urinary  apparatus,  or  to  the 
ingestion  of  medicinal  agents  or  of  poisons ;  while  ascend- 
ing nephritis  is  secondary  to  disease  of  the  lower  urinary 
organs,  or  to  catheterism  and  other  operations  upon  the 
urethra  or  bladder.  Both  kidneys  are  generally  involved, 
but  in  an  unequal  degree.  Descending  nephritis  may  arise 
without  microbic  invasion,  or  may  be  the  result  of  microbic 
invasion  ;  therefore  it  may  be  arnicrobic  or  microbic. 

Descending  arnicrobic  nephritis  is  the  outcome  of  long- 
continued  abuse  of  alcoholic  beverages,  of  large  doses  of 
potassium  iodide  and  other  irritants,  or  of  persistent  hyper- 
lithuria.  The  primary  effect  of  any  of  these  irritants  is 
upon  the  epithelial  cells  of  the  uriniferous  tubes,  which  un- 
dergo a  molecular  necrotic  process  and  are  cast  away  in 
great  numbers.  Thus  the  morbid  action  is  at  first  paren- 
chymatous, but  later  diffuses  itself  and  reaches  the  fibrous 
tissue  and  the  blood  and  lymph- vessels  constituting  the  in- 
tertubular substance.     The  kidney  greatly  swells  from  plas- 


76 


matic  exudation,  consisting  largely  of  leucocytes,  and  this 
product  of  the  plegmasia  gradually  undergoes  incomplete 
organization  and  finally  sclerous  degeneration  and  contrac- 
tion, rendering  the  organ  nodular  and  causing  it  to  shrivel, 
often  to  less  than  half  its  normal  dimensions — a  condition 
which  is  common  among  persons  far  advanced  in  age.  This 
was  formerly  designated  as  cirrhosis,  but  is  now  known  as 
sclerosis  of  the  kidney,  and  is  ordinarily  associated  with 
hepatic  sclerosis.  The  sclerosed  kidney  is  so  vulnerable 
that  the  copious  ingestion  of  irritants,  such  as  occurs  dur- 
ing a  debauch,  or  inhalation  of  ether  necessary  to  the  per- 
formance of  a  surgical  operation  upon  the  urethra  or  blad- 
der, is  likely  to  interrupt  or  even  abolish  the  function  of 
urination,  or  to  induce  a  superacute  phlegmasia,  which 
proves  fatal  in  a  very  short  time.  In  such  circumstances 
miliary  purulent  foci  are  often  found  on  close  necropsic 
inspection  of  the  kidneys. 

An  intemperate  man  of  middle  age,  brought  to  Bellevue 
Hospital  in  the  year  1870  on  account  of  a  luxation  of  the 
left  hip,  was  etherized  for  the  reduction  of  this  luxation, 
which  could  not  be  effected  after  more  than  an  hour  of 
manipulation.  In  two  days  he  was  again  etherized,  and 
kept  for  an  hour  under  the  influence  of  the  anaesthetic  agent, 
during  which  renewed  attempts  at  reduction  were  made, 
but  with  no  better  result.  It  was  ascertained  on  the  next 
morning  that  he  had  not  urinated.  A  catheter  was  then 
introduced  and  no  urine  escaped.  He  died  comatose  forty- 
eight  hours  after  the  last  attempt  at  reduction  of  the  luxa- 
tion.   The  necropsy  revealed  sclerosis  and  extreme  irregular 


77 


contraction  of  both  kidneys.  There  was  no  urine  in  the 
bladder.  It  was  evident  that  acute  phlegmasia  had  been 
superinduced  by  the  large  quantity  of  ether  eliminated. 

Similar  fatal  results  have  since  been  noted  in  a  number 
of  cases  from  elimination  by  the  kidneys  of  large  quantities 
of  ether  which  had  been  required  for  anaesthesia  during 
prolonged  surgical  operations. 

The  inhalation  of  ether,  even  for  a  comparatively  short 
time,  has  proved  so  dangerous  to  patients  with  diseased 
kidneys  that,  in  case  of  urgent  necessity  for  surgical  inter- 
ference, nitrous  oxide  should  be  substituted  as  a  much  safer 
anaesthetic  agent,  and  this  precaution  may  advantageously 
be  taken  in  doubtful  cases,  or  even  when  the  kidneys  are  not 
supposed  to  be  diseased. 

In  cases  of  persistent  hyperlithuria  it  occasionally  hap- 
pens that  some  of  the  uriniferous  tubes  are  blocked  by  ag- 
gregations of  uric-acid  crystals.  These  infarctions  may 
give  rise  to  retention  cysts  in  the  kidney,  to  chronic  inter- 
stitial nephritis,  or  to  acute  interstitial  nephritis  ending  in 
necrosis  of  the  surrounding  tissues  and  the  formation  of 
miliary  abscesses,  or  cause  one  large  chronic  abscess,  which 
finally  communicates  with  the  renal  pelvis.  If  in  the  last 
case  the  ureter  is  even  incompletely  obstructed,  ectasia  of 
the  renal  pelvis  follows. 

About  a  year  ago  a  case  of  renal  abscesses  and  pyone- 
phrosis was  observed  which  seemed  to  be  attributable  to 
this  cause.  Lumbar  nephrotomy  was  performed  by  Dr.  H. 
M.  Silver,  and  at  least  a  quart  of  pus  escaped.  There  was 
also  a  secondary  perinephric  abscess.     The  wound  healed 


78 

in  the  course  of  three  months,  but,  as  there  was  an  increas- 
ing swelling  at  the  seat  of  disease  during  the  fourth  month, 
the  doctor  performed  nephrectomy,  and  found  an  abscess 
in  the  substance  of  the  kidney.  The  patient  made  a  good 
recovery,  and  when  last  seen  appeared  to  be  well. 

Hydronephrosis  and  pyonephrosis  will  be  further  exam- 
ined under  the  section  ectatic  affections. 

Descending  amicrobic  nephritis  is  generally  subacute 
and  of  very  slow  development,  whether  caused  by  alcohol- 
ism, by  the  ingestion  of  other  poisons,  or  by  hyperlithuria. 
It  is  latent,  and  all  subjective  symptoms  are  therefore  want- 
ing, and  the  objective  symptoms  are  few.  Its  diagnosis  is 
based  principally  upon  the  knowledge  of  the  effects  of  these 
irritants  which  prepare  the  kidneys  for  an  accession  of  acute 
phlegmasia  from  any  of  the  causes  that  have  already  been 
detailed.  The  fact  to  be  constantly  borne  in  mind  is  that 
the  kidneys  of  persons  addicted  to  alcoholic  excesses,  or 
subject  to  hyperlithuria,  are  nearly  all  diseased  to  a  greater 
or  less  extent  and  very  vulnerable,  easily  attacked  by  any  of 
the  forms  of  acute  phlegmasia  and  incapable  of  resisting 
their  ill  effects.  Consequently,  the  greatest  circumspection 
should  be  exercised  in  the  indication  of  surgical  operations 
upon  such  subjects,  and  in  selecting  the  anaesthetic  agent. 

Descending  microbic  nephritis  arises  from  infectious  em- 
boli in  cases  of  pyosaprsemia  and  of  ulcerative  endocarditis. 
The  phlegmasia,  in  such  cases,  is  caused  by  the  mechanical 
occlusion  of  small  renal  blood-vessels  and  consequent  necro- 
sis of  the  intertubular  substance,  leading  to  the  formation 
of  multiple  purulent  foci  which  sometimes  coalesce  and  form 


79 


a  single  large  abscess.    In  this  case  the  phlegmasia  is  super- 
acute,  fulminating,  and  fatal  in  a  very  short  time. 

Ascending  nephritis  may  be  amicrobic  or  microbic. 

Ascending  amicrobic  interstitial  nephritis  occasionally  fol- 
lows surgical  operations,  even  such  as  simple  catheterism,  and 
is  generally  subacute  and  bilateral.  Sometimes,  however,  it 
is  superacute  and  occurs,  though  with  extreme  rarity,  in  pre- 
viously healthy  kidneys.  This  interstitial  nephritis  is  also 
the  outcome  of  ureteric  obstruction,  partial  or  complete, 
whether  from  pressure  by  a  neighboring  growth,  from  an 
impacted  urolith,  from  a  growth  in  the  ureter  itself,  or  from 
stenosis  of  the  ureter.  It  ordinarily  affects  only  one  kid- 
ney. In  exceptional  cases,  both  ureters  being  partially  ob- 
structed, both  kidneys  suffer.  Roberts,  of  Manchester,  Eng- 
land, and  other  observers  relate  cases  of  fatal  anuria  from 
complete  obstruction  of  both  ureters  by  impacted  uroliths. 
Obstruction  of  one  of  the  ureters  from  any  of  the  several 
causes  just  mentioned  gives  rise  to  retention  of  urine  in, 
and  to  ectasia  of,  the  renal  pelvis,  or  even  of  the  straight 
uriniferous  tubes — hydronephrosis ;  and  the  consequent  hy- 
draulic compression  is  such  as  to  cause  nephritis  with  final 
destruction  of  the  kidney  structure,  leaving  little  more  than 
a  multilocular  sac  of  fibrous  tissue.  Long-standing  hydro- 
nephrosis sometimes  becomes  pyonephrosis  from  sudden 
local  necrosis  due  to  disturbance  in  the  blood-supply  of  such 
renal  tissue  as  may  have  been  intact. 

Amicrobic  pyelonephritis  is  sometimes  caused  by  the 
presence  of  a  urolith  or  of  several  uroliths  in  the  renal  pel- 
vis, and  is  designated  as  calculous   pyelonephritis.      The 


80 


pus  in  these  cases  consists  of  migrated  leucocytes  that  have 
passed  through  the  mucous  membrane  to  attack  the  urolith 
and  have  died  in  their  struggle  to  destroy  the  irritating  host. 
Symptoms. — When  acute  interstitial  nephritis  is  due  to 
catheterism  or  to  some  other  surgical  operation,  its  symp- 
toms are  a  chill  lasting  from  fifteen  to  forty-five  minutes, 
followed  by  febrile  reaction,  or  recurring  slight  chills  of 
very  short  duration,  and  a  rise  of  body  temperature  at  night 
from  100°  to  102°  F.  This  nightly  rise  of  temperature 
and  the  consequent  sweating  disturb  the  patient's  sleep,  his 
pulse  is  unduly  frequent,  his  appetite  vanishes,  his  tongue 
is  furred  and  sometimes  dry,  he  is  more  or  less  nauseated, 
and  at  times  vomits  his  food ;  he  is  distressed  by  flatulency, 
and  rapidly  emaciates.  During  the  day  the  skin  is  dry  and 
harsh.  The  complexion  is  pale  and  sallow.  There  is  no 
deep-seated  pain  in  the  region  of  the  kidney,  but  only  some 
lumbago.  The  urine  gives  no  positive  indication,  except, 
of  course,  in  the  case  of  oliguria  and  of  chronic  diffuse  ne- 
phritis with  casts  of  the  uriniferous  tubes.  Some  of  these 
symptoms  may  be  noted  for  several  weeks  and  then  be  no 
longer  appreciable.  Resolution  may  or  may  not  have  oc- 
curred, and  on  slight  provocation,  such  as  an  untimely  cathe- 
terism, the  phlegmasic  process  may  be  rekindled  and  run  a 
rapid  course  toward  a  fatal  issue.  When,  however,  resolu- 
tion is  fairly  established  the  patient  soon  apparently  regains 
his  normal  condition,  but  his  kidneys  are  vulnerable  and 
very  liable  to  be  again  diseased.  When  this  condition  is 
provoked  by  catheterism  it  is  designated  as  urethral,  urina- 
ry, or  catheter  fever. 


81 


The  diagnosis  of  acute  interstitial  nephritis  is  not  easily 
made.  Although  this  phlegmasia  may  occur  without  the 
provocation  of  catheterism  or  of  other  operations,  it  is  gen- 
erally caused,  directly  or  indirectly,  by  some  sort  of  surgi- 
cal interference — directly  by  instrumentation,  and  indi- 
rectly by  the  irritation  of  the  kidneys  through  their  elimina- 
tion of  a  large  proportion  of  the  ether  necessary  for 
anaesthetic  purposes,  or  by  the  introduction  of  foreign  ele- 
ments, such  as  micro-organisms,  etc. 

It  is  often  difficult  to  distinguish  acute  interstitial  ne- 
phritis from  the  septicsemic  condition  induced  by  the  ab- 
sorption of  stale  urine,  from  pyosaprsemia,  or  even  from 
continued  fever.  Therefore  the  closest  inquiry  into  the 
symptoms  in  connection  with  the  pre-existing  state  of  the 
patient  and  the  nature  of  the  setical  factor  or  factors  is 
necessary  to  a  correct  diagnosis. 

The  prognosis  of  acute  interstitial  nephritis  is  good 
when  the  phlegmasia  attacks  normal  kidneys,  but  is  doubt- 
ful, if  not  positively  bad,  when  it  attacks  kidneys  that  have 
already  suffered.  When,  in  previously  normal  kidneys, 
acute  interstitial  phlegmasia  occurs,  resolution,  under  fa- 
vorable circumstances,  begins  in  the  course  of  a  week, 
and  the  patient  is  soon  well.  But  in  already  diseased 
kidneys  the  phlegmasic  process  is  liable  to  end  in  sup- 
puration. If  both  kidneys  suppurate,  oliguria,  anuria, 
and  death  ensue.  However,  oliguria,  and  even  anuria, 
are  not  necessarily  indications  of  suppuration  of  the  kid- 
neys, for  either  may  last  several  days  in  patients  that 
ultimately  recover  from  acute  nephritis.     A  patient  treated 


82 


twenty  years  ago  for  anuria  which  lasted  four  days  is  still 
alive. 

Anatomical  Characters. — On  gross  inspection  of  kid- 
neys, removed  after  death  from  acute  interstitial  nephritis, 
their  capsule  is  found  adherent  and  somewhat  opaque,  and 
its  vessels  are  distended  with  blood.  When  split  open 
along  the  outer  border  the  substance  bulges  on  account  of 
the  sudden  release  from  compression  of  the  intertubular 
exudate.  It  is  softer  than  natural,  except  in  cases  of  old 
sclerosis,  where  it  is  hard  and  nodular.  The  renal  pelvis  is 
sometimes  in  a  phlegmasic  state,  and  contains  alkaline 
purulent  urine.  The  pyramids  are  red  in  some  cases,  pale 
in  others,  and  streaked  with  lines  of  purulent  exudate.  In 
the  cortical  substance  there  are  often  great  numbers  of 
miliary  purulent  foci  distinctly  visible  to  the  naked  eye. 

Microscopical  examination  verifies  the  purulent  charac- 
ter of  the  exudate  in  the  intertubular  substance  of  the 
straight  and  convoluted  tubes. 

Treatment. — In  cases  of  disease  of  the  lower  urinary 
organs  the  liability  of  secondary  renal  disease  is  not  to  be 
underestimated,  and  measures  likely  to  be  preventive  of 
acute  interstitial  nephritis  should  invariably  be  taken  in  the 
management  of  such  cases.  These  measures  consist  in  the 
administration  of  diluent  drinks,  of  quinine  in  small  doses, 
of  tincture  of  the  chloride  of  iron  in  five-minim  doses,  etc. 
If  there  is  stagnant  urine,  it  should  be  carefully  drawn  off 
and  the  bladder  cleansed  at  least  once  each  day  with  anti- 
septic solutions.  If  there  is  urethral  stenosis,  cautious  slow 
dilatation  should  be  resorted  to  and  the  greatest  care   ob- 


83 

served  in  catheterism.  The  patient  should  be  protected 
against  inclement  weather  and  kept  indoors.  If  there  is 
stone  or  any  other  affection  in  the  bladder,  or  intractable 
urethral  stenosis,  indicating  an  operation,  the  most  rigid 
preparatory  treatment  should  be  instituted.  When  acute 
interstitial  nephritis  occurs  in  previously  normal  kidneys, 
and  the  diagnosis  is  promptly  made,  it  is  desirable  to  strive 
to  effect  deliquescence  of  the  phlegmasic  process.  This 
deliquescence  can,  however,  be  effected  only  during  the 
earlier  period  of  the  invasion.  To  this  end,  free  wet  cup- 
ping in  the  lumbar  regions,  followed  by  hot  fomentations, 
should  at  once  be  practiced,  and  a  hydragogue  cathartic 
administered.  Even  if  deliquescence  does  not  occur,  this 
treatment  is  likely  to  shorten  the  process  of  resolution. 
During  the  treatment  diaphoretics  should  be  freely  em- 
ployed, and  the  skin  well  sponged  with  warm  water  and 
alcohol  two  or  three  times  daily,  and  the  under-garments 
changed  each  time. 

When  acute  interstitial  nephritis  affects  already  dis- 
eased kidneys,  although  the  chances  of  recovery  are  de- 
cidedly lessened,  the  treatment  should  not  be  abandoned, 
but  should  be  as  active  as  in  the  case  in  which  an  attempt 
is  made  to  effect  deliquescence. 

Ascending  microbic  pyelonephritis  is  the  outcome  of 
neglected  urethral  or  prostatic  obstruction,  vesical  stones, 
tumors,  tuberculosis,  entozoa,  foreign  bodies,  or  injuries 
and  diseases  of  the  spinal  cord  leading  to  paraplegia, 
causing  stagnation  and  fermentation  of  urine  in  the  blad- 


84 

der,  and  of  tlie  use  of  unclean  surgical  instruments,  par- 
ticularly catheters.  The  phlegmasic  action  creeps  up  the 
ureters  and  reaches  the  renal  pelves  and  uriniferous  tubes, 
where  several  species  of  bacilli  and  micrococci  find  abundant 
sustenance,  multiply  rapidly,  and  finally,  invading  the  inter- 
tubular  substance,  constitute  one  of  the  mechanical  factors 
in  the  suppuration  which  generally  occurs  in  both  kidneys. 
The  process  at  first  may  be  very  slow,  and  the  struggle  be- 
tween the  leucocytes  and  microbia  may  last  several  weeks 
or  months,  in  rare  instances  several  years,  when  suddenly, 
perhaps,  on  the  accession  of  new  colonies  of  these  microbia, 
it  becomes  very  rapid,  and  sometimes  death  is  hastened  by 
the  supervention  of  a  superacute  phlegmasia  thus  induced 
or  incited  by  an  operation  which,  under  the  circumstances, 
no  prudent  surgeon  would  countenance.  Most  of  the  cases 
of  fulminating  pyelonephritis  with  multiple  renal  abscesses 
following  surgical  operations  occur  in  patients  who  had 
long  suffered  from  chronic  interstitial  nephritis,  either  de- 
scending or  ascending,  consequent  upon  chronic  alcohol- 
ism, hyperlithuria,  or  obstruction  of  the  lower  urinary 
organs. 

The  sytnptoms  of  this  form  of  pyelonephritis  are  simi- 
lar to,  but  more  pronounced  than,  those  of  acute  interstitial 
nephritis.  The  body  temperature  rises  higher.  Sometimes 
the  phlegmasia  is  ushered  in  by  a  violent  chill ;  sometimes 
the  chill  does  not  occur  until  excited  by  a  catheterism  or  other 
operation  which  ends  fatally  within  two  or  three  days — 
fulminating  urinary  fever — and  at  other  times  there  occur 
every  day  or  two  slight  chills,  which  continue  during  two  or 


85 


three  weeks,  and  lead  the  unwary  to  think  that  the  patient 
is  suffering  from  intermittent  fever.  It  is  to  be  noted  that 
the  body  temperature  in  these  cases  is  higher  at  night  and 
that  it  often  rises  above  105°.  When  pyelonephritis  is 
subacute  and  due  to  long-continued  urinary  obstruction 
there  is  generally  dull  continuous  pain  in  the  lumbar  re- 
gion and  tenderness  to  pressure  in  the  course  of  the  ureters, 
which  are  also  involved  in  the  phlegmasia  and  more  or  less 
dilated  by  the  column  of  dammed-up  urine,  which  contains 
a  considerable  quantity  of  creamy  pus.  Emaciation  is  pro- 
gressive and  rapid ;  flatulency,  nausea,  and  vomiting  are 
frequent.  The  features  are  sallow  and  pasty  ;  the  tongue 
is  dry,  brown,  and  fissured.  Finally,  there  are,  drowsiness 
muttering  delirium,  oliguria,  and  anuria. 

The  diagnosis  is  based  upon  the  history  of  the  disease 
and  the  characters  of  its  symptoms,  but  in  some  cases  th(' 
characteristic  symptoms  are  masked  or  there  are  no  pre- 
dominant symptoms,  and  the  nature  of  the  affection  is  not 
known  until  revealed  by  the  necropsy. 

The  prognosis  of  microbic  pyelonephritis  is  bad,  but 
the  affection,  as  before  stated,  may  last  long — that  is  to 
say,  the  patient  may  survive  an  attack  of  subacute  pyelo- 
nephritis many  months,  and  in  some  cases  one,  two,  or  three 
years.  The  acute  and  superacute  types  terminate  fatally 
in  from  one  to  four  weeks,  delirium,  oliguria,  and  anuria 
supervening  a  few.  days  before  death. 

The  gross  necropsic  appearances  of  the  kidneys  vary  in 
degree,  but  are  of  the  same  kind.  The  capsule  is  adher- 
ent, the  kidney  substance  is  soft,  sometimes  pulpy  and  yel- 


86 


lowish,  and  mottled  with  congested  blood.  Tlie  pelves  and 
calices  are  dilated  to  a  greater  or  less  extent  and  their 
mucous  membrane  is  red  in  patches,  seldom  of  uniform 
redness,  coated  with  a  thin  layer  of  slimy  pus,  and  the  pel- 
ves and  ureters  are  filled  with  highly  purulent  urine,  the 
ureters  being  more  or  less  dilated. 

Microscopical  examination  reveals  dilatation  of  the 
straight  uriniferous  tubes,  and  streaks  of  pus  with  colonies 
of  bacteria  within  and  between  these  tubes,  purulent  foci  in 
the  cortex,  and  here  and  there  blood  infarctions.  The  epi- 
thelial cells  of  the  cortical  tubes  are  opaque  and  swollen 
and  many  of  them  in  a  necrotic  state.  The  intertubular 
substance  is  infiltrated  with  bacteria  and  with  leucocytes 
which  have  been  vanquished  in  their  struggle  with  these 
microbia  and  have  consequently  become  pus.  The  microbia 
even  reach  the  glomeruli,  many  of  which  are  shriveled,  and 
their  capsules  appear  to  be  thicker  than  normal. 

Treatment. — In  the  management  of  microbic  pyelo- 
nephritis it  should  be  remembered  that  any  unrelieved 
source  of  urinary  obstruction  leads  to  stagnation  and  fer- 
mentation of  urine  in  the  bladder,  causing  in  time  grave 
alterations  of  structure  in  the  kidneys,  to  which  palliative 
measures  only  are  applicable.  In  the  case  of  urethral  stenosis 
these  palliative  measures  consist  in  gradual  dilatation  of  the 
strictured  urethra.  In  the  case  of  prostatic  obstruction, 
they  consist  of  periodical  evacuative  catheterism.  In  both 
cases  they  consist  in  counteracting  fermentation  of  urine  in 
the  bladder  by  frequent  irrigations  with  antiseptic  fluids. 

The  quantity  of  urine  passed  each  day  should  be  con- 


stantlv  kept  in  view.  In  case  of  oliguria  or  of  polyuria, 
prompt  measures  should  be  taken  tending  to  re-establish 
the  normal  secretion  of  the  urine.  In  case  of  oliguria, 
which  is  sometimes  the  forenmner  of  anuria,  mild  diuretics 
and  diaphoretics  are  indicated.  Digitalis  infusion  and  small 
doses  of  alkaline  diuretics,  such  as  acetate  or  citrate  of 
potassium,  and  borage  tea,  or  any  other  similar  beverage, 
answer  the  purposes  of  diuresis  and  diaphoresis.  In  case 
of  polyuria,  ergot  extract  in  pills  may  be  given  in  doses  of 
two  or  three  grains,  repeated  three  or  four  times  daily. 
Gallic  acid,  in  five-grain  doses  dissolved  in  glycerin,  is  also 
sometimes  useful  in  cases  of  excessive  polyuria.  The  re- 
mainder of  the  general  medication  consists  in  opiates  to 
relieve  pain,  diluents,  occasionally  moderate  doses  of  ben- 
zoic acid  and  biborate  of  sodium,  reconstituents,  mild  stimu- 
lants, and  a  properly  regulated  diet.  Such  local  and  general 
medication  gi-eatly  promotes  the  comfort  of  patients,  and  in 
some  instances  helps  to  prolong  life. 

Perixephritis — phlegmasia  of  the  connective-adipose 
envelope  of  the  kidney — arises  as  an  acute,  a  subacute,  or 
a  chronic  affection.  In  the  first  two  states  this  phlegmasia 
may  speedily  resolve,  or  resolution  may  be  imperfect  and 
end  in  chronic  induration  of  the  adipose  capsule,  or  sup- 
puration may  take  place  and  a  vast  perinephric  abscess  may 
be  formed.  The  chronic  may  begin  without  pre'vious  acute 
or  subacute  phlegmasia,  and  may  be  discovered  only  after 
death. 

Rayer,  Feron,  Halle,  Trousseau,  Xaudet,   Lecygne,  Po- 


88 


land,  Dickinson,  Duffin,  Ebstein,  Nieden,  Bowditch,  G-ib- 
ney,  Morris,  and  many  others  have  elucidated  the  nature, 
aetiology,  semeiology,  diagnosis,  and  therapeusis  of  peri- 
nephritis, and  more  than  a  hundred  special  articles  on  the 
subject  have  been  published  in  the  last  thirty  years. 

Rayer  collected,  in  1839,  a  number  of  published  cases 
of  abscess  in  the  ilio-costal  region,  and  described  with 
masterly  accuracy  and,  having  defined,  named  perinephri- 
tis this  phlegmasia  of  the  cellulo-adipose  capsule  of  the 
Mdney. 

This  affection  occurs  at  nearly  all  periods  of  life  from 
the  first  few  years  to  advanced  age.  In  an  interesting- 
series  of  j)apers.  Dr.  V.  P.  Gibney  reports  twenty-eight 
cases  of  perinephritis  in  children,  of  which  five  were  under 
three  years  of  age,  twelve  between  three  and  six  years, 
eight  between  six  and  ten  years,  and  three  between  ten  and 
fifteen  years.  Thirteen  of  these  were  males  and  fifteen 
were  females.  The  right  side  was  affected  in  six  and  the 
left  side  in  seven  of  the  males.  The  right  side  was  affected 
in  eight  and  the  left  side  in  seven  of  the  females. 

Of  one  hundred  and  sixty-six  cases  reported  by  Meden, 
twenty-three  were  under  fifteen  years  of  age. 

Naudet  regards  perinephritis  as  an  affection  of  adults, 
as  rare  in  old  age  and  still  more  rare  in  childhood,  and  does 
not  seem  to  have  known  of  a  sufferer  from  this  ailment 
younger  than  ten  years. 

Lecygne  is  of  opinion  that  perinephritis  occurs  mainly 
during  the  most  active  periods  of  life — ^.  e.,  from  the  ages 
of  thirty  to  sixty,  then  from  ten  to  twenty. 


89 


The  question  of  this  relative  frequency  can  be  decided 
only  by  the  analysis  of  many  thousands  of  cases. 

Perinephritis  sometimes  occurs  as  a  primary  affection, 
which  may  or  may  not  result  from  injury,  but  which  is  in- 
dependent of  any  kidney  lesion.  It  is  oftener  consecutive 
to  injuries  or  to  affections  of  the  kidney — such  as  nephric 
abscesses,  pyelitis,  pyonephrosis,  pyelonephritis,  calculous 
concretions,  parasites,  tuberculosis,  malignant  disease,  etc. 
— and  it  is  also  consecutive  to  caries  of  the  vertebrae,  ul- 
ceration of  the  small  intestine  and  colon,  and  to  disease  of 
other  organs. 

Primary  perine'phritis  is  said  to  be  occasionally  due  to 
dyscrasic  influences  such  as  give  rise  to  gout  and  rheuma- 
tism, but  most  commonly  it  is  due  to  strains,  contusions, 
and  wounds. 

Of  the  one  hundred  and  sixty-six  cases  of  perinephritis 
collected  by  Nieden,  twenty-four  were  primary. 

Contusions,  strains,  and  falls  were  the  causes  in  eight 
of  Dr.  Gibney's  twenty- eight  cases ;  in  nineteen  of  these 
cases  the  exciting  cause  could  not  be  ascertained. 

Of  twenty-eight  cases  of  perinephric  abscess  due  to 
primary  perinephritis,  tabulated  by  Poland,  the  causes  are 
stated  as  follows  :  Falls  and  contusions  in  three  cases,  jolt- 
ing in  carriage  in  one,  fatigue  in  walking  in  one,  mus- 
cular effort  (digging)  in  three,  debility  in  one,  uncertain 
and  insidious  in  four,  no  assignable  cause  in  six,  cause  not 
stated  in  six,  and  doubtful  in  three  cases  (Morris). 

Secondary  perinephritis  is  most  frequently  consecutive 
to  renal  affections.     A  nephric  abscess  may  be  so  near  the 


90 


surface  of  the  kidney  that  perinephritis  is  soon  established 
by  this  propinquity,  but  some  time  may  elapse  before  the  ne- 
phric  abscess  opens,  if  it  open  at  all,  into  the  peripheral  pus 
cavity.  In  the  case  of  pyonephrosis  the  pus  may  pass 
through  a  perforation  of  the  wall  of  the  dilated  renal  pelvis 
into  the  peripheral  connective  tissue  and  cause  an  extensive 
perinephric  abscess,  just  as  in  pyelonephritis  the  tissue  de- 
struction and  the  communication  may  be  through  the  sub- 
stance of  the  kidney.  This  is  sometimes  effected  by  the 
irritating  presence  of  a  calculus,  of  parasites,  of  tuberculosis, 
or  of  malignant  disease. 

In  a  case  of  left  perinephric  abscess  seen  in  con- 
sultation eleven  years  ago  the  necropsy  showed  the  sup- 
puration to  be  owing  to  urinary  infiltration  due  to  the 
destruction  of  renal  tissue  by  the  rapid  extension  and 
softening  of  malignant  disease  primarily  affecting  the 
kidney. 

In  a  large  proportion  of  cases  perinephritis  is  consecu- 
tive to  disease  of  organs  other  than  the  urinary,  such  as 
perforation  of  the  ileum,  colon,  or  gall-bladder,  as  peri- 
typhlitis, pulmonary  abscess,  or  caries  of  the  vertebrae,  and 
even  to  affections  of,  and  operations  upon,  some  of  the  pel- 
vic organs.  The  kidney  substance  is  sometimes  attacked 
and  in  part  destroyed  by  the  phlegmasia  which  began  in 
the  peripheral  adipose  tissue,  so  that  pus  is  discharged  into 
the  urinary  bladder. 

Of  twenty-six  cases  of  perinephric  abscess  collected  by 
Duffin,  twelve  were  consecutive  to  affections  of  organs  other 
than  the  urinary. 


91 


The  symptoms  of  perinephritis  vary  with  the  cause  and 
the  intensity  of  the  phlegmasic  process.  In  primary  peri- 
nephritis, supposed  to  be  due  to  dyscrasic  influences,  the 
phlegmasia  being  subacute,  there  is,  in  the  lumbar  region,  a 
constant  dull  pain  sometimes  regarded  as  simple  lumbago, 
and  many  months  may  elapse  before  tumefaction  and  ten- 
derness to  pressure  are  appreciable.  The  movements  of  the 
patient,  though  somewhat  impeded,  intensify  the  existing 
local  pain,  w^hich  is  then  propagated  to  the  thorax,  to  the 
inguinal  region,  and  even  to  the  lower  extremity.  This 
irradiation  of  the  pain  leads  the  sufferer  to  believe  himself 
the  subject  of  muscular  rheumatism,  and  the  nature  of  his 
real  ailment  is  unrecognized  until  a  marked  tumefaction  is 
revealed  and  fluctuation  detected.  Meanwhile  he  had  often 
had  a  rise  of  body  temperature  and  had  been  restless  at 
night,  his  appetite  had  vanished,  he  had  sometimes  vomited 
his  food,  had  been  distressed  with  flatulency  and  constipa- 
tion, emaciation  had  begun,  his  strength  had  failed,  and  for 
several  weeks  he  had  been  unable  to  make  even  slight  mus- 
cular exertion  without  greatly  increasing  his  local  pain,  and 
unable  to  extend  the  thigh  on  the  affected  side  without 
much  suffering.  In  these  cases  the  urine  gives  no  indica- 
tion other  than  the  presence  of  an  abundance  of  urates,  with 
high  specific  gravity. 

When  primary  perinephritis  is  the  outcome  of  a  severe 
contusion  or  some  other  grave  injury,  the  symptoms  are 
more  quickly  appreciable  as  a  general  rule.  The  phleg- 
masia being  acute  in  the  majority  of  cases,  the  pain  is 
greater  and  is  much  intensified  by  movements  of  the  lower 


92 

limbs,  and,  though  this  pain  follows  the  course  of  the  lum- 
bar and  sciatic  nerves,  its  point  of  greatest  intensity  is  the 
loin,  which  is  hard,  tense,  bulging,  and  tender  to  pressure. 
In  the  course  of  ten  or  twelve  days  the  pain  is  lancinating, 
excruciating  from  pressure  by  increased  exudation,  and  at 
nightfall  come  rigors  and  febrile  reaction.  The  thigh  is 
flexed  upon  the  pelvis  for  the  relief  in  part  of  the  existing 
tension  and  pain.  A  marked  swelling  then  occupies  the 
ilio-costal  space,  and  sometimes  extends  inward  toward  the 
median  line  and  downward  into  the  iliac  region.  These 
parts  are  oedematous,  and  the  oedema  spreads  into  adjacent 
tissues  upward  upon  the  thorax  and  downward  into  the  in- 
guinal, gluteal,  and  femoral  regions,  rendering  difficult  the 
detection  of  fluctuation  in  the  lumbar  region.  The  integu- 
ment in  or  about  the  ilio-costal  space  sometimes  assumes 
an  erysipelatous  redness,  an  indication  that  the  pus  is 
rapidly  extending  itself  toward  the  surface. 

The  symptoms  of  consecutive  perinephritis,  whether  due 
to  nephric  abscess,  to  pyonephrosis,  or  to  diseases  of  other 
organs,  are  similar  in  kind  but  not  in  degree  to  those  of 
primary  perinephritis.  But  these  symptoms  are  often 
masked  by  those  of  the  particular  affection  which  has 
caused  the  perinephritis.  For  instance,  pyonephrosis  is 
diagnosticated,  an  operation  is  decided  upon,  the  incision 
in  the  flank  is  made,  a  few  ounces  of  pus  flow  from  an 
unsuspected  perinephric  abscess,  and  the  swelling  is  little 
diminished  until  a  deeper  cut  is  made,  when  perhaps 
a  quart  of  pus  escapes  from  the  dilated  kidney  and-  the 
swelling  vanishes.      This  happened   in   the  case  cited_  to 


93 


illustrate  pyonephrosis  due  to  partial  obstruction  of  tlie 
ureter. 

In  tlie  case  of  consecutive  perinephritis  due  to  calculous 
pyelonephritis,  many  months  or  even  years  may  elapse  be- 
fore the  symptoms  are  manifested,  and  while  the  nature  of 
the  pyelonephritis  is  ascertained  partly  through  the  occur- 
rence of  repeated  attacks  of  nephritic  colic  and  the  expul- 
sion of  small  calculi  by  the  natural  passage,  the  perinephri- 
tis is  undiscovered  until  a  lumbar  operation  reveals  its 
existence. 

The  same  difficulty  occurs  in  the  perception  of  the  symp- 
toms of  consecutive  perinephritis  due  to  disease  of  other 
organs  by  which  it  is  masked  until  the  swelling  at  the  ilio- 
costal space  is  well  defined. 

In  children  the  symptoms  of  consecutive  perinephritis 
are  even  less  appreciable  than  in  adults,  for  they  often  close- 
ly simulate  those  of  spinal  and  hip-joint  disease  until  the 
ilio-costal  tumefaction  is  evident,  this  affection  and  spinal 
caries  sometimes  coexisting. 

The  progress  of  perinephritis  may  be  so  rapid  that  its 
several  stages  follow  in  quick  succession  and  the  termina- 
tion may  be  resolution  or  gangrene,  but  most  commonly  it 
ends  in  the  formation  of  an  abscess  within  ten  or  twelve 
days ;  or  this  progress  may  be  very  slow  and  suppuration 
may  not  take  place  for  many  months  or  years  after  the  be- 
ginning of  the  phlegmasic  process. 

Under  favorable  circumstances  the  process  of  resolution 
ends  in  from  two  to  three  weeks. 

The  early  writers  on  this  subject,  particularly  Rayer, 


94 


considered  resolution  to  be  an  extremely  rare  termination 
of  perinephritis,  but  later  experiences,  with  early  and  accu- 
rate diagnosis,  and  perhaps  improved  therapic  measures, 
give  a  fair  proportion  of  cases  of  primary  perinephritis  that 
have  terminated  in  resolution  without  suppuration. 

Rayer  does  not  appear  to  have  seen  a  single  case  of 
perinephritis  terminate  in  resolution  without  suppuration. 

Halle  cites  only  one  case  which  appeared  to  be  a  peri- 
nephritis and  ended  in  resolution,  but  he  had  a  doubt  as  to 
the  correctness  of  the  diagnosis. 

Trousseau  reports  a  case  in  which  the  diagnosis  of  acute 
primary  perinephritis  was  undoubted,  and  which  terminated 
in  resolution  without  suppuration. 

Naudet  mentions  only  one  case  which  resolved  without 
suppuration . 

Twelve  of  Gibney's  twenty-eight  cases  (1876  to  1880) 
ended  in  resolution  without  suppuration. 

Further  examination  of  the  question  will  probably  show 
that  resolution  occurs  oftener  in  primary  perinephritis  than 
it  even  now  appears. 

Gangrene  is  a  very  rare  termination  of  perinephritis. 
Rayer  cites  only  two  cases,  one  of  which  he  credits  to  Dr. 
Thomas  Turner  (1812)  and  the  other  to  Bland  (1818).  In 
Turner's  case,  he  says,  the  affection  was  fulminating  and 
the  patient  died  at  the  end  of  the  second  day.  The  autopsy 
revealed  gangrene  of  the  adipose  capsule  of  both  kidneys, 
forming  a  black,  pulpy  mass.  In  Bland's  patient  the  gan- 
grene was  probably  due  to  urinary  infiltration  of  the  adi- 
pose capsule. 


95 


When  suppuration  occurs,  its  duration  varies  with  the 
cause  of  the  perinephritis,  the  general  condition  of  the  pa- 
tient, and  the  direction  taken  by  the  pus.  In  perinephritis 
due  to  perforation  of  the  renal  pelvis  or  substance  by  a  stone, 
the  suppuration  persists  until  the  calculous  mass  is  removed 
or  discharged,  weeks,  months,  or  years  after  its  formation. 

In  a  case  of  perinephric  abscess  opened  by  the  late  Dr. 
James  R.  Wood,  pus  continued  to  flow  through  a  lumbar 
fistula  for  more  than  fifteen  years.  Occasionally  this  fistula 
was  obstructed  by  small  stones  which  were  finally  expelled. 

The  ordinary  course  taken  by  the  pus  of  perinephric 
abscesses  is  backward  in  the  lumbar  region,  but  it  has  been 
known  to  burrow  downward  into  the  pelvic  cavity  and  open 
into  the  bladder,  rectum,  or  vagina,  down  into  the  gluteal 
and  even  the  femoral  region,  or  upward  into  the  pleural 
cavity  and  cause  empyema,  into  the  lung  and  there  cause  a 
secondary  abscess  which,  if  it  open  into  a  large  bronchus, 
is  expectorated,  or  it  .may  open  into  the  stomach  or  some 
other  part  of  the  intestinal  tract.  It  very  rarely  enters  the 
peritoneal  cavity. 

What  may  be  the  average  duration  of  perinephritis  is 
another  question  which  can  be  answered  only  after  the 
analysis  of  great  numbers  of  well-recorded  cases.  However, 
this  phlegmasia,  when  uncomplicated,  runs  the  course  of 
phlegmasise  in  general. 

In  twenty-seven  of  the  twenty-eight  cases  treated  by 
Dr.  Gibney,  the  phlegmasia  "  ran  its  course  in  an  average 
period  of  about  three  months  and  a  half."  This  includes 
the  twelve  cases  which  ended  in  resolution.     One  case  not 


96 


included  in  the  computation  "  seemed  to  extend  over  a  pe- 
riod of  two  years  and  a  half." 

In  the  great  majority  of  cases  of  perinephritis  termi- 
nating in  suppuration  the  phlegm asic  process  is  quickly 
modified,  and  often  as  quickly  arrested  as  soon  as  free  exit 
is  given  to  the  pus. 

A  case  seen  with  Dr.  Stephen  Smith  in  January,  1891, 
is  a  fair  illustration  of  the  rapidity  of  cure  sometimes  af- 
forded by  free  incision  and  thorough  disinfection.  The 
patient,  a  man  of  twenty-seven,  had  been  ill  for  six  weeks 
from  pain  in  the  right  loin,  but  could  give  no  further  ac- 
count of  himself.  At  the  time  of  the  visit  he  appeared 
dazed  and  typhic.  The  ilio-costal  space  was  prominent, 
the  integument  in  that  space  was  oedematous  and  red,  and 
the  oedema  and  redness  extended  into  the  inguinal  region. 
A  question  arose  as  to  whether  the  case  was  one  of  peri- 
nephritis or  perityphlitis,  or  of  both,  but  Dr.  Smith  was 
inclined  to  believe  that  the  swelling  was  due  to  a  suppurat- 
ing perinephritis.  An  exploratory  operation  was  advised, 
and  was  performed  on  the  following  day.  The  abdominal 
cavity  was  opened,  but  no  perityphlitis  was  found,  and  the 
wound  was  closed.  A  lumbar  incision  then  gave  issue  to  a 
copious  flow  of  thick,  greenish  pus.  The  abscess  cavity 
was  thoroughly  washed  with  a  solution  of  mercuric  chloride, 
a  drainage-tube  was  introduced,  and  the  wound  stitched. 
From  that  moment  there  was  no  more  pus  formation,  and  in 
twenty-five  days  the  parts  seemed  entirely  consolidated,  the 
drainage-tube  having  been  retained  two  weeks  for  periodi- 
cal irrigation. 


97 

The  diagnosis  of  'perinephritis  is  often  attended  with  dif- 
ficulties, particularly  in  its  early  stage  before  tumefaction 
is  palpable,  and  it  is  sometimes  difficult  even  after  the  oc- 
currence of  suppuration.  In  primary  perinephritis  the  his- 
tory of  injury  in  the  lumbar  region  is  of  great  help,  but 
the  patient  may  not  then  remember  to  have  been  hurt,  and 
the  cause  of  his  ailment  may  be  unknown.  At  its  onset 
the  deep-seated  local  pain  is  worthy  of  consideration, 
though  it  is  not  strictly  a  diagnostic  symptom,  as  it  may 
arise  from  some  other  cause,  such  as  typhoid  and  eruptive 
fevers,  and  it  may  be  several  days  before  this  pain  can  be 
distinguished  from  that  which  characterizes  these  fevers.  A 
point  Tv^orth  bearing  in  mind  is  that  in  typhoid  and  eruptive 
fevers  the  pain  is  in  both  lumbar  regions,  is  irradiated 
throughout  the  muscular  system,  and  is  attended  with  great 
general  lassitude  and  prostration. 

Later,  when  tumefaction  is  manifest,  it  may  be  con- 
founded on  the  left  side  with  splenitis,  or  with  impaction 
of  faeces  in  the  descending  colon ;  on  the  right  side  with 
hepatic  abscess,  or  with  typhlitis  or  perityphlitis ;  and  on 
either  side  with  renal  abscess.  Here  again  the  diagnosis  is 
arrived  at  by  the  method  of  exclusion. 

Still  later,  when  suppuration  has  taken  place,  especially 
when  the  abscess  formation  is  slow,  it  may  be  confounded 
with  hydronephrosis,  pyonephrosis,  or  hydatid  cysts  ;  but,  on 
careful  analysis  of  the  symptoms,  these  affections  are  soon, 
one  by  one,  excluded  from  further  consideration.  These 
three  affections  are  to  be  excluded  when  the  phlegmasic 
process  is  characterized  by  oedema  of  the  integuments,  a 


98 


deep,  doughy  sensation  on  palpation,  tenderness  on  pressure, 
and  acute  pain.  In  liydroneplirosis  and  hydatid  cysts  there 
occur  neither  rigors  nor  febrile  reaction.  In  any  doubtful 
case  an  exploratory  puncture  or  incision  is  indicated,  and 
this  generally  establishes  the  diagnosis. 

Two  other  morbid  conditions  are  sometimes  confounded 
with  perinephric  abscess — caries  of  the  vertebrae  and  coxi- 
tis— and  this  error  has  led  to  special  treatment  for  these 
affections  until  the  abscess  has  pointed  in  the  lumbar  region 
and  has  been  relieved  by  incision,  when  all  the  signs  of  ver- 
tebral or  hip  disease  have  vanished. 

In  the  case  of  a  small  perinephric  abscess  the  diagnosis 
is  uncertain,  and  the  exploratory  incision  by  which  it  may 
be  established  is  warranted  only  by  symptoms  such  as  fre- 
quently recurring  rigors  and  continuous  deep-seated  lumbar 
pain. 

In  the  treatment  of  perinephritis  the  first  indication  is  to 
strive  to  effect  resolution  ;  this  failing  and  suppuration  en- 
suing, the  second  indication  is  to  promptly  give  exit  to  the 
pus,  and  the  third  indication  is  to  endeavor  to  thoroughly 
disinfect  the  a,bscess  cavity. 

Even  if  there  is  a  doubt  as  to  the  existence  of  peri- 
nephritis, the  symptoms  of  phlegmasia  in  the  lumbar  region 
warrant  a  vigorous  antiphlogistic  treatment,  which  should 
be  instituted  as  soon  as  the  first  symptoms  are  manifested. 
For  this  end,  six  or  eight  wet  cups  or  a  dozen  leeches  should 
be  applied  to  the  loin  on  the  affected  side.  The  cupping 
or  leeching  should  be  followed  by  hot  fomentations  for  two 
or  three  days.    The  existing  constipation  should  be  relieved 


99 


by  a  cathartic,  and  the  catharsis  kept  up  by  salines.  Ano- 
dynes should  be  given  in  sufficient  doses  to  relieve  pain  and 
insure  sleep.  On  the  third  or  fourth  day  blistering,  pro- 
duced by  vesicating  collodion,  may  be  resorted  to  with  ad- 
vantage. .  The  blistered  spaces  need  not  be  over  two  inches 
in  diameter,  but  this  blistering  should  be  repeated  every 
second  day,  each  time  on  a  different  spot,  and  allowed  to 
dry  up  without  suppuration.  During  the  blistering,  which 
may  be  continued  for  two  weeks,  the  fomentations  should 
be  replaced  by  a  thick  layer  of  dry  absorbent  cotton.  If, 
during  this  time,  the  pain,  tenderness,  and  swelling  per- 
ceptibly diminish,  this  subsidence  indicates  that  resolution 
is  going  on,  and  the  process  may  then  be  promoted  by  in- 
unction of  the  ilio-costal  space  twice  daily  with  a  salve 
composed  of  one  ounce  of  belladonna  ointment,  one  ounce 
of  simple  cerate,  and  two  drachms  of  potassic  iodide,  the 
whole  region  to  be  covered  with  absorbent  cotton.  The 
diet  should  be  simple  but  nourishing,  and  the  strength  of 
the  patient  maintained,  if  necessary,  by  the  free  exhibition 
of  alcoholic  stimulants. 

The  antiphlogistic  treatment,  if  it  is  to  be  successful, 
should  produce  the  most  marked  modification  of  the  phleg- 
raasic  process  during  the  first  few  days ;  otherwise  if,  in 
the  course  of  ten  or  twelve  days,  there  should  be  much  fe- 
brile reaction,  increased  and  increasing  tumefaction  with 
oedema  of  the  integuments,  whether  or  not  fluctuation  is 
detected,  it  is  almost  certain  that  suppuration  has  begun. 
Then,  without  delay  or  hesitation,  a  free  incision  should  be 
made  in  the  lumbar  region  corresponding  to  the  anterior 


100 


border  of  the  quadratus  lumborum  muscle,  and  the  dissec- 
tion carried  through  the  aponeurosis  of  the  flat  abdominal 
muscles  close  to  the  border  of  the  quadratus,  meanwhile 
securing  all  bleeding  vessels  until  the  abscess  wall  is  reached 
and  freely  incised.  The  index  finger  is  then  introduced 
before  the  abscess  is  emptied,  and  the  nature  of  the  peri- 
nephritis ascertained.  If  a  free  calculus  is  detected,  it 
should  be  extracted  without  delay.  But  if  only  a  part  of  a 
calculus  projects  into  the  abscess  cavity,  the  knife  or  the 
thermo-cautery  is  necessary  to  enlarge  the  opening  through 
which  it  projects  from  the  kidney,  and  great  caution  should 
be  observed  in  its  extraction,  which  is  effected  by  lithotomy 
forceps.  Sloughs  of  connective  tissue  may  be  loosened  with 
the  finger  and  extracted  with  dressing  forceps. 

The  third  indication,  the  disinfection  of  the  abscess 
cavity,  is  effected  by  means  of  the  ordinary  irrigating  appa- 
ratus used  by  surgeons.  The  irrigation  should  be  begun 
with  a  warm  solution  of  mercuric  chloride  (1  to  10,000)  and 
five  per  cent,  of  peroxide  of  hydrogen.  After  using  three 
or  four  pints  of  this  solution,  its  strength  may  be  increased 
to  1  to  5,000  and  ten  per  cent,  of  peroxide  of  hydrogen. 
The  irrigation  should  be  continued  until  the  escaping  fluid 
is  clear  and  entirely  free  from  pus.  A  large  drainage-tube 
should  then  be  introduced,  and  the  wound  stitched  and 
suitably  dressed. 

Under  favorable  circumstances  the  abscess  cavity  is  soon 
obliterated  and  the  external  wound  healed.  It  is,  however, 
wise  to  keep  the  drainage-tube  in  position  for  ten  days  or 
two  weeks,  irrigating   once   a   day,  even   if  no   more   pus 


101 

should  flow.  The  brevity  of  the  convalescence  after  this 
operation  is  sometimes  surprising.  In  Dr.  Smith's  case 
there  was  no  suppuration  after  the  disinfection  of  the  ab- 
scess cavity,  and  the  patient  was  well  in  twenty-five  days. 

In  some  cases  of  consecutive  perinephric  abscess  it  is 
not  wise  to  encourage  early  closure  of  the  wound,  and  an 
ample  drainage-tube  should  be  kept  in  position  and  short- 
ened from  time  to  time  until  the  cavity  is  obliterated. 


102 


V. 


Cystitis  ;  its  Causes,  Symptoms,  Progress,  Anatomical 
Characters,  Diagnosis,  and  Prognosis. 

Uro-cystitis — phlegmasia  of  the  urinary  bladder — is 
most  frequently  confined  to  its  mucous  membrane — myxo- 
cystitis ;  sometimes  it  invades  the  submucous  fibrous  coat 
and  the  muscular  coat — interstitial  cystitis  ;  and  rarely 
reaches  the  peripheral  connective  tissue  and  peritoneal  cov- 
ering— pericystitis.  Some  of  the  writers  of  the  last  cent- 
ury regarded  cystitis  as  a  phlegmasia  of  all  the  coats  of  the 
bladder.  When  the  phlegmasia  was  confined  to  the  mucous 
coat  they  termed  the  affection  catarrhal  fluxion  of  the  blad- 
der, or  catarrh  of  the  bladder.  Later  the  term  catarrhal 
cystitis  was  adopted  to  signify  phlegmasia  of  the  vesical 
mucous  membrane,  supposed  to  be  attended  with  a  great 
flow  of  mucus. 

Causes. — This  phlegmasia,  which  occurs  with  great  fre- 
quency at  nearly  all  periods  of  life,  is  consecutive  to  renal, 

urethral,  or  prostatic  affections,  and  to  injuries  and  other 
I 

local  irritants.     Its  causes  may  therefore  be  arranged  into 

the  following  four  groups,  and  each  group  into  sundry  spe- 
cies and  varieties  of  causes :  1.  Cystitis  arising  from  devia- 
tions in  quantity  or  quality  of  the  urinary  secretion.  2. 
Cystitis  arising  from  the  extension  of  phlegmasic  action  of 
neighboring  organs.     3.   Cystitis  arising   from  injuries  of 


103 


the  bladder  and  from  other  local  irritants.  4.  Cystitis 
arising  from  stagnation  and  fermentation  of  urine  due  to 
obstructed  urination. 

1.  Cystitis  arising  from  Deviations  in  Quantity  or 
Quality  of  the  Urinary  Secretion. — Any  marked  deviation 
from  the  normal  standard  of  quantity  or  quality  of  the  uri- 
nary secretion  is  liable  to  cause  cystitis.  When  there  is 
much  increase  in  quantity — polyuria — dependent  upon  dis- 
turbed innervation  or  structural  disease  of  the  kidneys, 
this  urine  of  very  low  specific  gravity  rapidly  distends  the 
bladder,  whose  epithelium  becomes  water-logged,  its  super- 
ficial stratum  is  cast  away,  and  the  irritant  urine  induces  in 
the  capillaries  of  the  mucous  membrane  a  suflicient  degree 
of  congestion  to  permit  the  emigration  of  great  numbers 
of  leucocytes,  which,  reaching  the  surface  and  dying,  be- 
come pus.  If  the  urine  be  examined  microscopically  dur- 
ing the  early  days  of  an  excessive  and  persistent  polyuria, 
it  will  be  observed  that  quantities  of  vesical  epithelial  cells 
have  been  washed  away  by  the  great  flood  of  pale  urine 
and  much  swollen  by  endosmosis.  Examined  later,  it  is 
found  that  these  epithelial  cells  are  much  exceeded  in  num- 
bers by  pus-corpuscles,  and  that  the  urine  contains  also  some 
red  blood-cells. 

When  the  urine  is  decreased  in  quantity — oliguria — its 
specific  gravity  is  increased  from  excess  of  solid  matter. 
It  is  thereby  rendered  acrid  and  irritating  to  the  mucous 
membrane,  and  soon  causes  cystitis.  Certain  poisons  in- 
duce oliguria  when  taken  for  a  long  time,  notably  opium. 
To  what  extent  those  who  make  inordinate  use  of  this  drug 


104 

suffer  from  vesical  irritability  is  worthy  of  particular  in- 
quiry on  tlie  part  of  tlie  physicians  who  have  charge  of  such 
patients. 

Congestion  of  the  vesical  mucous  membrane  from  any 
cause  renders  this  membrane  -sTilnerable  even  by  normal 
urine.  One  of  the  causes  of  vesical  congestion  deserving 
more  consideration  than  it  generally  receives  is  disturbance 
of  the  cutaneous  circulation.  This  disturbance  arises  from 
different  diseases,  and  also  from  certain  injuries  of  the 
skin. 

Paludal  fevers,  with  frequently  recurring  rigors,  and  the 
so-called  congestive  fever,  are  attended  with  oligaemia  of  the 
body  surface  and  consequent  congestion  of  the  internal  or- 
gans and  of  the  mucous  membranes.  The  kidneys  at  first 
secrete  scantily,  and  the  urine,  overcharged  with  solid  mat- 
ter, irritates  the  congested  bladder.  Sychnuresis  is  the  im- 
mediate result.  Later  the  secretion  greatly  increases  and 
washes  away  much  of  the  bladder  epithelium.  The  urine 
soon  becomes  turbid  from  the  presence  of  pus  and  of  saline 
precipitates.  There  is  then  a  subacute  general  myxo-cysti- 
tis,  which,  however,  ceases  soon  after  the  removal  of  the 
original  cause. 

Any  extensive  laceration  or  ablation  of  the  cutaneous 
surface  causes  shock,  rigors,  and  internal  congestion.  The 
urine,  at  first  scanty,  soon  increases  in  quantity  and  con- 
stitutes the  irritant  exciting  cause  of  the  cystitis. 

Extensive  burns  of  the  skin  also  constitute  an  indirect 
cause  of  cystitis.  From  the  examination  of  statements 
made  by  Dupuytren,  Nelaton,  Legouest,  and  others,  and  from 


105 


the  observation  of  cases  in  Bellevue  Hospital,  it  seems  that 
extensive  burns  of  the  surface  of  the  body  have  often  been 
the  indirect  cause  of  cystitis.  But  to  ascertain  the  propor- 
tion of  cases  of  cystitis  caused  by  burns  would  require  ex- 
tended investigation.  Theoretical  reasons,  clinical  observa- 
tion, and  necropsic  evidence  have  been  furnished  by  careful 
investigators,  from  the  time  of  Dupuytren,  to  explain  the 
mechanism  of  the  cystitis  thus  indirectly  caused.  The 
earliest  phenomena  noted  of  extensive  burns  of  the  body, 
irrespective  of  degree,  are  shock,  rigors  foUow^ed  by  febrile 
reaction,  inordinate  thirst,  frequent  desire  to  urinate,  and 
congestion  of  the  mucous  membranes.  These  phenomena, 
and  especially  the  congestion,  are  accounted  for  partly  by 
the  sudden  disturbance  of  the  nervous  system  and  of  the 
cutaneous  circulation.  Granting  the  occurrence  of  conges- 
tion of  the  vesical  mucous  membrane,  then  normal  urine, 
even  in  small  quantity,  is  sufficiently  irritating  to  this  con- 
gested membrane  to  cause  at  first  frequent  and  urgent 
urination  and,  later,  cystitis.  Impairment  of  the  function 
of  the  great  gland,  the  skin,  such  as  results  from  extensive 
burns,  is  apt,  in  a  short  time,  to  impose  much  additional 
work  of  elimination  upon  the  kidneys,  and  the  resulting 
polyuria  aggravates  the  beginning  cystitis  induced  by  the 
first  irritant,  which  may  have  been  a  urine  diminished  in 
quantity,  but  surcharged  with  solid  matter,  or  even  normal 
urine  in  quantity  and  quality. 

Exposure  to  humid  cold  is  spoken  of  by  many  authors 
as  a  cause  of  cystitis,  doubtless  with  clinical  foundation,  but 
generally  with  no  explanation  as  to  how  and  why  humid 


106 


cold  produces  this  effect  upon  the  bladder.  Exposure  to 
humid  cold  is  sometimes  the  indirect  cause  of  cystitis  be- 
cause, like  paludal  and  congestive  fevers,  it  causes  prima- 
rily some  disturbance  of  the  cutaneous  circulation  leading 
to  congestion  of  the  vesical  raucous  membrane  and  render- 
ing it  vulnerable  by  the  urine  which  is  the  excitant  of  the 
cystitis. 

The  effect  upon  the  vesical  mucous  membrane  of  varia- 
tions in  the  quality  of  the  urine  also  requires  some  notice. 
Persistent  hyperlithuria,  so  common  among  dyspeptics,  is  a 
very  frequent  cause  of  cystitis.  Highly  acid  urine,  whether 
increased  or  decreased  in  quantity  but  containing  an  excess 
of  uric  acid,  mechanically  irritates  the  bladder  and  excites 
phlegmasia  of  a  greater  or  less  extent  of  its  inucous  mem- 
brane, beginning  generally  at  or  near  the  urethro-vesical 
orifice,  which  is  pricked  at  each  act  of  urination  by  the  al- 
most innumerable  sharp-pointed  crystals.  Some  of  the 
most  distressing  cases  of  cystitis  begin  in  this  way.  Per- 
sistent oxaluria,  by  the  same  mechanism,  causes  trachelo- 
cystitis.  Alkaline  urine,  as  will  be  seen  later,  likewise 
causes  cystitis. 

Pyuria  from  chronic  pyelitis  also  gives  rise  to  cystitis 
of  the  lower  fundus,  partly  from  fermentation  and  the  irri- 
tating action  of  carbonate  of  ammonium  evolved  from  the 
fermentative  process. 

Glycosuria  is  another  cause  of  cystitis  which  is  not  in- 
frequently overlooked.  In  cases  of  excessive  glycosuria, 
with  or  without  polyuria,  saccharine  fermentation  is  liable 
to  occur  and  cause  very  distressing  cystitis. 


107 

Cantliaridine,  taken  internally  or  absorbed  by  the  skin 
from  Spanish-fly  blisters  and  eliminated  by  the  kidneys, 
is  a  powerful  irritant  to  the  vesical  mucous  membrane  and 
causes  trachelocystitis  with  very  painful  stranguria.  The 
French,  who  sometimes  use  the  resin  of  thapsia  as  a 
counter-irritant,  think  that  its  absorption  and  elimination 
by  the  kidneys  produce  effects  similar  to  those  of  canthari- 
dine. 

Turpentine  causes  cystitis,  either  when  taken  internally 
in  poisonous  doses,  or  through  gradual  saturation  of  the 
system  by  inhalation  of  its  fumes,  as  occurs  among  work- 
men in  varnish  factories  or  among  sailors  on  "  turpentine 
ships,"  some  of  the  men  being  attacked  with  nephritis, 
trachelocystitis,  and  even  urethritis,  attended  sometimes 
with  profuse  haematuria. 

Excesses  in  alcohol,  new  beer,  and  cider-drinking  are 
often  potent  factors  in  the  causation  of  cystitis. 

Ether,  when  inhaled  during  one  or  two  hours  for  anaes- 
thetic purposes,  being  largely  eliminated  by  the  kidneys, 
induces  at  first  oliguria,  then  polyuria.  In  cases  of  pro- 
longed anaesthesia  perfect  consciousness  is  not  ordinarily 
restored  for  three  or  four  hours  after  cessation  of  the  ether 
inhalation.  Sensation  remains  blunted  and  the  mind  some- 
what cloudy  for  some  time  after  this,  so  that  any  discomfort 
caused  by  urinary  accumulation  in  the  bladder  is  vaguely 
attributed  either  to  the  region  of  the  late  operation  or  to 
some  distant  part  of  the  body.  Unless  particular  inquiry 
or  an  examination  is  made,  the  bladder  becomes  so  over- 
distended  in  the  course  of  twelve  hours  that  the  patient  can 


108 


not  urinate  at  will.  This  overdistention,  together  with  the 
congestion  induced  by  the  irritant  ether,  causes  a  cystitis 
which  often  persists  many  weeks  and  sometimes  becomes 
chronic.  This  cystitis  is  not  an  uncommon  accident  of 
many  surgical  operations  necessitating  prolonged  anaes- 
thesia. 

Careful  inquiry  into  possible  setical  factors  serves  to 
eliminate  cases  of  so-called  idiopathic  cystitis. 

2.  Cystitis  arising  from  the  Extension  of  Phlegmasic 
Action  of  Neighboring  Organs. — Trachelocystitis  is  some- 
times caused  by,  or  rather,  as  Fournier  says,  may  be  a  phase 
of,  urethritis,  a  result  of  the  extension  of  the  phlegmasia  to 
the  urethro-vesical  orifice  on  or  about  the  third  week  of  the 
urethritis.  Though  believing  that,  in  the  majority  of  cases, 
it  comes  without  provocation,  he  acknowledges  that  trache- 
locystitis may,  during  urethritis,  be  excited  by  sexual  in- 
tercourse, alcoholic  excesses,  irritating  injections,  catheter- 
ism,  etc. 

Trachelocystitis  is  sometimes  excited  by  gonecystitis, 
prostatitis,  haemorrhoids,  proctitis,  etc. 

3.  Cystitis  arising  from  Injuries  of  the  Bladder  and  from 
other  Local  Irritants. — Unduly  frequent  catheterism  some- 
times does  violence  to  the  epithelium  at  the  urethro-vesical 
orifice,  and  thus  causes  subacute  or  acute  trachelocystitis, 
and  is  liable,  in  the  same  way,  to  cause  general  myxo- 
cystitis,  more  particularly  when  unclean  instruments  are 
used.  Violent  catheterism  causes  cystitis  by  contusing  or 
by  tearing  the  neck  or  body  of  the  bladder.  Contusions  or 
wounds  of  the  bladder  directly  cause  cystitis,  and  also  in- 


109 


directly  by  leaving  behind  some  foreign  body  as  the  irri- 
tant, such  as  a  clot  of  blood,  a  bullet,  a  scale  of  bone,  a 
piece  of  the  clothing  of  the  wounded  person,  etc. 

Among  the  irritants  known  to  cause  cystitis  are  calculi, 
foreign  bodies,  entozoa,  new  growths,  and  tuberculosis.  No 
comments  need  be  made  at  present  upon  these  causative 
agents,  except  in  the  case  of  the  entrance  into  the  bladder 
of  some  of  the  foreign  substances  that  reach  it  from  the 
small  and  large  intestines  and  from  without.  Knuckles  of 
small  intestine  sometimes  become  adherent  to  the  peri- 
toneal coat  of  the  bladder  and,  by  ulceration,  allow  the  in- 
trusion of  different  substances  besides  a  part  of  their  con- 
tents into  the  vesical  cavity.  Thus  needles,  fish-bones, 
seeds,  and  other  objects  pass  from  the  intestines  into  the 
bladder  and  give  rise  to  cystitis.  In  a  dissecting-room 
specimen  it  was  discovered  that  three  knuckles  of  the  ileum 
had  become  firmly  adherent  to  the  upper  part  of  the  blad- 
der, and  that  between  each  of  these  knuckles  and  the  blad- 
der there  was  an  opening,  nearly  circular,  with  smooth 
edges,  and  about  half  an  inch  in  diameter.  Judging  from 
the  appearance  of  the  parts,  the  ulcerations  had  probably 
occurred  several  months  before  death.  It  was  also  evident 
that  the  existing  cystitis  was  caused  by  the  constant  passage 
of  the  intestinal  contents  into  the  bladder.  In  a  case  of 
iliac  abscess  from  ulceration  of  the  appendix  vermiformis, 
occurring  in  a  boy,  the  tumefaction  suddenly  subsided,  and 
the  patient's  urine  was  found  to  contain  fsecal  matter.  The 
consequent  cystitis  did  not  last  very  long,  and  the  boy  made 
a  good  recovery.     There  are  many  cases  on  record  where 


110 


faeces  and  different  foreign  bodies  had  passed  from  tlie  rec- 
tum into  tlie  bladder  to  cause  cystitis  and  become  the  nuclei 
of  pliospbatic  stones. 

The  prolonged  retention  of  catheters  for  drainage  of 
the  bladder,  broken  ends  of  catheters,  and  other  foreign 
bodies  introduced  from  without  are  among  the  many  factors 
in  the  causation  of  cystitis. 

4.  Cystitis  arising  from  Stagnation  and  Fermentation  of 
Urine  due  to  Obstructed  Urination. — The  first  effect  of  ob- 
structed urination,  whether  from  urethral  stenosis,  prostatic 
obstruction,  or  urethro-vesical  contracture,  is  a  series  of 
spasmodic  contractions  of  the  bladder  which  is  thus  in- 
cessantly wrestling  with  the  obstacle  to  the  expulsion  of  the 
urine.  If  this  be  not  artificially  relieved,  the  struggle  con- 
tinues week  after  week  and  month  after  month.  During 
that  time  the  stream  of  urine  steadily  diminishes  in  size 
and  force,  and  the  bladder  does  not  completely  empty  itself. 
The  stagnant  urine  soon  undergoes  fermentation,  followed 
by  the  evolution  of  carbonate  of  ammonium,  which  is  a  po- 
tent factor  in  the  production  of  the  cystitis. 

Some  diseases  and  injuries  of  the  brain  or  spinal  cord 
are  followed  by  retention  of  urine,  said  to  be  due  to  paraly- 
sis of  the  bladder.  If  complete  paralysis  of  the  bladder 
occurs  it  seems  as  though  there  should  be  incontinence  and 
not  retention  of  urine.  In  cases  of  disease  or  injury  of  the 
nervous  centers,  is  not  the  retention  of  urine  due  to  im- 
paired sensation  in  the  bladder,  which  then  allows  the  urine 
to  accumulate  and  distend  it,  the  disease  or  injury  of  these 
nervous  centers  interfering  with  their  reception  of  the  im_ 


Ill 

pression  of  the  need  to  urinate  ^  Carefully  observed  cases 
seem  to  indicate  tliat  some  lesions  of  tlie  nervous  centers 
which  disturb  the  action  of  the  bladder  do  not  cause  com- 
plete paralysis  of  that  viscus,  for  closure  of  the  urethro- 
vesical  orifice  is  not  interfered  with,  but  its  voluntary  open- 
ing is  impossible,  owing  to  loss  of  the  sensibility  which  is 
so  necessary  to  express  the  need  to  urinate.  The  pathic 
conditions  which  result  from  this  loss  of  sensibility  are 
contracture  of  the  urethro-vesical  orifice,  stagnation  and 
fermentation  of  the  urine,  and  cystitis.  In  a  number  of 
autopsies  made  at  Bellevue  Hospital,  upon  cases  of  fracture 
of  the  spine  with  paraplegia,  the  bladder  was  almost  in- 
variably found  inflamed,  dilated,  and  sometimes  thickened. 
In  some  cases  surviving  the  injury  several  months,  phos- 
phatic  calculi  were  found  in  the  bladder  and  in  the  renal 
pelves. 

The  four  groups  of  fetical  factors  give  rise  to  acute,  sub- 
acute, and  chronic  cystitis.  The  symptoms  of  each  of  these 
three  types  of  cystitis  will  next  be  examined. 

The  symptoms  of  cystitis  vary  according  to  the  particu- 
lar site,  cause,  severity,  and  stage  of  the  phlegmasia,  but  the 
several  types  of  cystitis  present  some  symptoms  that  are 
common  to  all  of  them.  These  are  disturbances  in  urina- 
tion, pain,  and  deviations  from  the  normal  characters  of 
the  urine. 

The  earliest  local  symptom  of  acute  cystitis,  whether  of 
the  body,  lower  fundus,  or  neck  of  the  bladder,  is  unduly 
frequent  urination.    This  is  soon  followed  by  spasm  of  the 


112 


muscular  coat  excited  by  irritation  of  the  congested  mucous 
membrane  ;  tlie  urine  intensifying  tbis  irritation  may  be  de- 
creased or  increased  in  quantity,  and  may  be  of  bigb  or  of 
low  specific  gravity.  During  tlie  period  of  increase  of 
tracbelocystitis  the  urine  is  passed  in  short  interrupted 
spurts,  often  in  drops,  with  the  greatest  distress,  and  in 
some  cases  more  than  a  hundred  times  in  the  twenty -four 
hours.  At  times  urination  is  irrepressible,  and  the  gar- 
ments are  soiled  with  urine.  In  rare  instances  there  is  re- 
tention of  urine.  These  anomalies  of  urination  are  due 
partly  to  swelling  at  the  urethro-vesieal  orifice  and  partly 
to  spasm  of  the  whole  bladder.  The  pain  during  urination 
extends  to  the  distal  extremity  of  the  urethra  in  chronic  as 
well  as  in  subacute  and  acute  tracbelocystitis,  but  is  most 
intense  in  the  acute  type,  when  it  is  characterized  by  pa- 
tients as  scalding,  burning  ;  reaching  its  maximum  of  inten- 
sity during  the  expulsion  of  the  last  drops  of  urine,  and  is 
associated  with  rectal  tenesmus  and  sometimes  irrepressible 
defecation. 

In  cases  of  vesical  injury,  stone,  foreign  bodies,  and  re- 
tention of  urine,  there  is  pain  in  the  bladder  independent 
of  urination,  and  this  pain  is  often  irradiated  to  the  ab- 
dominal organs,  to  the  lumbar  region,  and  along  the  nerves 
of  the  lower  extremities,  and  is  much  intensified  by  sudden 
movements  of  the  body.  In  cystitis  of  the  neck  and  lower 
fundus  the  pain  is  aggravated  by  accumulation  of  faeces  or 
by  any  other  source  of  compression  in  the  rectum.  When 
the  body  of  the  bladder  is  implicated,  the  slightest  pressure 
applied  to  the  hypogastric  region  gives  very  much  pain. 


113 

The  deviations  from  the  normal  characters  of  the  urine 
in  acute  cystitis  are  increase  of  acidity,  excess  of  uric  acid, 
and  the  presence  of  pus  and  blood  in  greater  or  less  quaii- 
tity.  In  trachelocystitis,  attended  with  strangurr,  the 
small  quantity  of  urine  voided  each  time  is  mixed  with 
blood  and  pus,  and  with  mucus  derived  from  the  urethro- 
vesical  region,  the  prostate,  and  the  glands  of  the  urethra. 
In  cystitis  due  to  stagnation  of  urine  there  is  an  abundant 
precipitate  of  ammonio-magnesian  phosphates,  and  the 
urine  is  alkaline,  slimy,  highly  purulent,  and  contains  much 
exfoliated  vesical  epithelium. 

The  symptoms  of  chronic  cystitis  without  obstruction  of 
urination  are  of  the  same  kind,  but  of  lesser  degree  than 
those  of  acute  cystitis,  the  presence  in  the  urine  of  more  or 
less  pus  and  exfoliated  vesical  epithelium  being  amono-  its 
essential  characters. 

The  symptoms  of  chronic  cystitis  due  to  prostatic  or 
urethral  obstruction  are  frequent,  difficult,  and  painful  uri- 
nation ;  the  small  stream  of  alkaline,  purulent  urine  being 
often  interrupted,  and  the  act  of  urination  failing  to  relieve 
the  bladder,  which  may  be  distended.  This  type  of  cystitis 
is  accompanied  by  a  dull,  constant  pain  along  the  ureters, 
extending  up  to  the  kidneys.  The  patients  complain  of 
lumbago  and  sciatica,  and  often  seek  the  physician's  advice 
for  these  aches  rather  than  on  account  of  the  uriuarv  stao-- 
nation  and  cystitis. 

The  constitutional  symptoms  of  cystitis  vary  with  the 
intensity  of  the   phlegmasia   and   also  with   its  cause.     In 

acute  trachelocystitis  due  to  the  extension  of  urethritis  the 

8 


114 


pain  is  rarely  such  as  to  cause  much  general  disturbance, 
and  there  is  no  febrile  reaction,  no  inconvenience  except 
during-  urination.  It  is  only  when  urination  is  very  fre- 
quent— every  ten  minutes — and  accompanied  with  tenes- 
mus, that  the  patient  complains  of  being  much  ill  at  ease, 
for  he  is  deprived  of  sleep,  is  feverish  at  night,  and  loathes 
his  food ;  but  these  symptoms  are  at  their  height  during 
the  period  of  increase,  which  rarely  lasts  longer  than  three 
or  four  days. 

In  trachelocystitis  due  to  the  action  of  cantharidine 
the  constitutional  symptoms  are  proportionate  in  degree  to 
the  amount  of  the  poison  absorbed.  In  moderate  quantity, 
the  poison  causes  only  such  general  effects  as  are  induced 
by  pain  and  want  of  rest ;  but  when  the  quantity  of  can- 
tharidine is  great,  as  when  administered  by  the  ignorant  or 
by  others  with  nefarious  intent,  the  constitutional  effects 
are  often  alarming  and  sometimes  fatal. 

Superacute  cystitis  involving  nearly  if  not  all  the  tunics 
of  the  bladder  is  attended  with  very  grave  symptoms,  such 
as  recurring  rigors,  constant  fever,  vomiting,  general  depres- 
sion, and  signs  of  purulent  infection  or  of  intercurrent  peri- 
tonitis. 

When  retention  of  urine  occurs  either  in  acute  or  in 
chronic  cystitis  and  the  bladder  becomes  much  overdis- 
tended,  the  constitutional  symptoms  are  of  the  gravest  or- 
der and  often  point  to  a  fatal  issue. 

The  progress  of  cystitis  corresponds  in  a  great  measure 
with  its  cause  and  type,  with  the  previous  condition  of  the 


115 


bladder,  and  witli  the  age,  constitutional  peculiarities,  and 
general  health  of  the  patient. 

Cystitis  arising-  from  deviations  in  quantity  and  quality 
of  the  urinary  secretion  continues  as  long  as  the  exciting- 
agent  is  operative,  often  long  after  it  is  removed,  and  some- 
times becomes  chronic.  In  those  cases  arising  indirectly 
from  disturbance  of  the  cutaneous  circulation  the  cystitis 
has  been  observed  to  resolve  in  a  few  days,  but  occasionally 
it  passes  through  its  several  stages  and  lasts  many  weeks  or 
months.  The  following  case  is  given  as  an  example  of  the 
ordinary  course  of  cystitis  caused  indirectly  by  an  extensive 
burn.  In  this  case  the  polyuria,  though  not  extreme,  seems 
to  have  lasted  longer  than  it  should,  as  it  continued  several 
weeks  after  the  greater  part  of  the  burned  skin  had  healed. 

A  man,  twenty-seven  years  of  age,  was  admitted  into 
Bellevue  Hospital  on  the  23d  of  May,  1891,  three  hours 
after  he  had  been  burned  in  the  face,  thorax,  epigastrium, 
and  upper  extremities.  The  accident  happened  while  he 
was  varnishing  with  shellac  and  alcohol  the  interior  of  a 
beer  vat  ;  the  safety  lamp  used  for  illumination  having  ex- 
ploded, set  the  varnish  on  fire,  and  before  he  could  get  out 
of  the  vat  his  clothing  and  the  several  parts  of  his  body 
just  mentioned  were  burned.  Though  the  burns  were  very 
extensive,  affecting  about  one  fourth  of  the  body  surface, 
they  were  not  all  equally  deep,  and  ranged  from  the  second 
to  the  fourth  degree.  In  a  few  places  only  did  they  reach 
the  fourth  degree,  while  in  the  greater  part  of  the  injured 
skin  of  the  face  and  body  the  burns  did  not  exceed  the  sec- 
ond degree.     At  one  o'clock  p.  m.  on  the  day  of  his  admis- 


116 

sion  tlie  tlaermometer  showed  liis  body  temperature  to  be 
101°  ;  bis  respiration  was  tben  24  a  minute,  and  bis  pulse 
110.  At  nine  o'clock  p.  m.  bis  temperature  bad  risen  to 
104°.  His  respiration  was  18  and  bis  pulse  140.  After- 
ward tbere  were  lluctuations  between  104°  and  100°  in  his 
temperature,  wbicb  did  not  become  normal  until  tbe  IStb  of 
June,  wben  all  tbe  more  superficial  burns  were  bealed.  Tbe 
pulse  bad  tben  fallen  to  72  a  minute.  Tbe  respirations 
for  several  days  fluctuated  between  18  and  22  a  minute. 
On  tbe  first  day  of  tbe  accident  be  bad  great  tbirst  and 
an  almost  incessant  desire  to  urinate.  On  tbe  second  and 
tbird  days  be  urinated  every  five  and  ten  minutes  and  tbe 
urine  was  dark  and  scanty.  For  tbe  following  four  days 
tbe  intervals  of  urination  increased  gradually  to  fifteen  min- 
utes, balf,  tliree  quarters,  and  finally  one  bour.  Tbe  urine 
bad  tben  become  turbid.  Polyuria  began  on  tbe  seventh 
day  after  the  accident.  Before  this  accident  be  was  in  the 
habit  of  urinating  only  three  or  four  times  a  day.  From 
tbe  2d  of  June  a  faithful  record  was  kept  of  each  act 
of  urination  and  of  tbe  quantity  of  urine  passed.  This 
record  shows  that  be  urinated  fourteen  times  in  the  first 
twenty-four  hours,  ten  days  after  tbe  accident,  passing  in 
all  seventy-one  ounces  of  urine.  Tbe  greatest  quantity  of 
urine  passed  by  tbe  patient  during  any  twenty-four  hours 
was  one  hundred  and  three  ounces  ;  this  was  twenty  days 
after  tbe  accident ;  and  tbe  smallest  quantity  was  fifty-seven 
ounces — eleven  days  after  the  accident.  The  greatest  quan- 
tity passed  at  any  one  act  of  urination  was  twenty-eight 
ounces,  and  tbe   smallest   quantity   was  two  ounces.     The 


117 

urine  was  not  examined  microscopically  until  tlie  twelfth 
day  of  the  accident.  It  was  then  found  to  contain  pus. 
The  quantity  of  pus  gradually  decreased,  though  the  patient 
received  no  local  treatment  for  his  cystitis.  On  June  20th, 
twenty-eight  days  after  the  accident,  the  urine  was  found, 
on  microscopical  examination,  to  contain  an  abundance  of 
octahedral  crystals  of  oxalate  of  calcium,  some  vesical  epi- 
thelium, and  a  few  pus  cells.  On  June  25th  the  polyuria 
had  decreased  to  sixty-eight  ounces.  He  continued  as  an 
out-patient  and  was  under  treatment  for  the  burns  of  the 
upper  extremities,  which  were  not  completely  healed  in  the 
latter  part  of  August,  1891,  the  polyuria  having  decreased 
but  little. 

Cystitis  due  to  persistent  hyperlithuria  deliquesces  or 
resolves  very  rapidly  as  soon  as  a  suitable  general  treatment 
renders  the  urine  innocuous  ;  but  when  the  hyperlithuria  is 
overlooked,  the  phlegmasia  invades  the  whole  vesical  mu- 
cous membrane  and  the  submucous  connective  tissue.  Con- 
tracture, diminished  capacity,  and  thickening  of  the  bladder 
ensue,  and  the  patient  is  much  distressed  by  the  very  fre- 
quent and  painful  expulsion  of  purulent  and  bloody  urine, 
even  after  the  affection  has  become  chronic. 

Cystitis  due  to  the  action  of  cantharidine  deliquesces  in 
a  few  hours  when  the  quantity  of  the  poison  absorbed  is 
little,  otherwise  the  phlegmasia  is  more  violent  and  exten- 
sive and  the  urine  is  purulent  for  weeks  or  months. 

The  progress  of  trachelocystitis  arising  from  the  ex- 
tension of  phlegmasic  action  of  neighboring  parts  is  very 
rapid  when,  under  suitable  treatment,  the  period  of  increase 


118 


is  cut  short,  so  that  at  the  end  of  three  or  four  days  urina- 
tion is  less  frequent  and  less  painful.  The  tenesmus  ceases, 
the  urine  is  passed  in  larger  quantity,  and  is  clearer.  In 
such  cases  resolution  is  effected  in  the  course  of  eight  or 
ten  days.  In  severer  cases,  particularly  when  treatment  is 
delayed,  resolution  is  not  complete  under  three,  four,  or  six 
weeks,  and  in  some  instances  the  phlegmasia  passes  into  the 
chronic  state  and  the  whole  of  the  vesical  mucous  mem- 
brane may  become  involved.  Cystitis  from  injuries  of  the 
bladder,  and  from  other  mechanical  irritants,  such  as  foreign 
bodies,  calculi,  etc.,  continues  with  greater  or  less  violence 
until  the  irritant  is  removed,  and  may  require  very  active 
treatment  long  afterward.  Soon  after  the  ablation  of  be- 
nign new  growths  the  phlegmasia  rapidly  subsides,  but  such 
is  not  the  case  with  malignant  disease  and  tuberculosis. 

Cystitis  arising  from  stagnation  of  urine  due  to  urethral, 
urethro-vesical,  or  prostatic  obstruction  is  gradually  and 
slowly  developed,  beginning  sometimes  with  the  characters 
of  subacute  and  sometimes  with  those  of  chronic  phleg- 
masia. 

In  the  case  of  obstruction  from  urethral  stenosis,  if  en- 
largement of  the  contracted  part  of  the  urethra  be  effected 
before  the  bladder  is  very  seriously  damaged,  the  phleg- 
masia subsides  or  even  disappears ;  otherwise  ureteric  and 
pyelic  ectasia  and  phlegmasia  ensue,  and  the  supervention 
of  complete  retention  of  urine  from  a  debauch  in  Baccho  et 
Venere  is  to  be  regarded  as  a  very  serious  complication. 

Similar  phenomena  arise  from  neglected  urethro-vesical 
and  prostatic  obstruction.     In  the  case  of  unrelieved  com- 


119 

plete  retention  of  urine  from  prostatic  obstruction  the  blad- 
der becomes  greatly  distended  and  sometimes  the  upper 
urinary  organs  are  implicated  beyond  remedy. 

A  case  seen  in  consultation  in  May,  1891,  will  serve  to 
illustrate  the  progress  of  neglected  prostatic  obstruction  and 
cystitis.  The  patient,  seventy-three  years  of  age,  had  been 
suffering  for  six  years  from  unduly  frequent  and  at  times 
irrepressible  urination.  He  had  persistently  refused  to  be 
catheterized  until  the  last  week  of  his  life,  and  for  four 
months  had  been  greatly  harassed  by  sychnuresis,  passing 
only  a  few  drachms  of  urine  each  time.  When  seen  he  was 
extremely  emaciated  and  very  feeble.  His  bladder  was 
much  distended,  extending  up  to  the  umbilicus  and  project- 
ing forward  very  much  as  does  the  pregnant  uterus  at  the 
sixth  month.  It  was  not  deemed  prudent  to  empty  this 
bladder  at  one  sitting,  therefore,  when  ten  ounces  of  urine 
had  been  withdrawn,  the  catheter  was  removed  and  not 
again  used  until  the  expiration  of  three  hours,  when  twelve 
ounces  of  clear  urine  escaped  which  apparently  contained 
but  a  small  quantity  of  pus.  After  this,  it  was  agreed  that 
one  pint  be  drawn  off  four  times  each  day.  Palpation  of 
the  abdomen  then  revealed  great  ectasia  of  the  left  ureter, 
which  was  at  first  mistaken  for  a  knuckle  of  small  intestine. 
The  right  ureter  could  not  be  felt.  Although  the  bladder 
was  in  this  manner  gradually  emptied  in  the  course  of  three 
days,  and  all  untoward  consequences  to  the  organ  that 
would  have  arisen  from  its  sudden  evacuation  were  thus 
averted,  the  patient  gradually  sank  and  died  one  week  after. 
No  autopsy  was  made.     Aside  from  the  effects  of  the  over- 


120 


distention  of  his  bladder,  the  patient  was  in  fair  general 
condition,  and  had  he  consented  to  be  regularly  catheter- 
ized,  even  a  few  months  before  the  fatal  event,  he  would 
have  been  spared  great  suffering  and  would  not  have  died 
from  the  consequences  of  retention  of  urine. 

Another  grave  consequence  of  retention  of  urine  may 
here  be  incidentally  stated,  and  that  is  the  profuse  haemor- 
rhage which  sometimes  follows  the  too  precipitate  evacuation 
of  the  overdistended  bladder  in  elderly  men  suffering  from 
prostatic  obstruction  and  cystitis.  This  phenomenon  may 
be  thus  explained :  In  overdistention  of  the  bladder  its 
coats  are  greatly  stretched ;  the  capillary  vessels  of  the  mu- 
cous membrane  are  likewise  stretched  and  consequently 
weakened.  When,  therefore,  the  mechanical  support  given 
by  the  accumulated  urine  is  suddenly  removed,  the  extreme 
tension  of  the  vesical  parietes  is  succeeded  by  extreme 
flaccidity ;  the  nearly  empty  capillaries  are  almost  instantly 
gorged  with  blood,  and  their  delicate  walls  give  way  before 
the  sudden  impulse  of  the  refluent  blood  which  soon  begins 
to  ooze  from  thousands  of  minute  rents  of  the  mucous 
membrane.  In  some  cases  the  bladder  has  been  found 
greatly  distended  with  clotted  blood. 

Polyuria  sometimes  follows  the  precipitate  evacuation 
of  the  distended  bladder.  It  has  been  observed  in  several 
instances  in  great  excess.  In  one  case  it  reached  twenty- 
seven  pints  (four  hundred  and  thirty-two  ounces)  in  twenty- 
seven  consecutive  hours.  From  this  it  gradually  decreased 
to  ninety-six  ounces  each  day.  In  three  months  the  amount 
of  urine  in  the  twenty-four  hours  was  not  below  sixty-four 


121 

ounces,  and  a  year  expired  before  it  dropped  to  forty-eight 
ounces  in  the  twenty -four  hours.  This  is  an  extreme  case ; 
but  polvuria  to  a  hundred  ounces  is  not  uncommon  in  these 
cases,  particular!}'  when  there  coexists  either  renal  sclerosis 
or  hydronephrosis. 

In  the  case  of  stagnation  of  urine  from  disease  or  in- 
jury of  the  nervous  centers,  as  well  as  from  urethral  or 
prostatic  obstruction,  unless  catheterism  be  regularly  em- 
ployed, the  phlegmasia  progresses  from  bad  to  worse  until 
the  upper  urinary  organs  are  implicated.  There  is  in  these 
cases  a  constant  liability  to  calculous  formation  in  the 
bladder  and  renal  pelves. 

Normal  Appearances  of  the  Bladder. — In  studying 
the  patho-anatomy  of  cystitis,  the  normal  appearances  of  the 
bladder  should  be  borne  in  mind,  particularly  the  thickness 
of  its  walls  and  the  color  of  its  mucous  membrane. 

The  bladder  walls  consist  of  five  coats — four  complete 
and  one  incomplete.  The  external  or  peritoneal,  the  thin- 
nest of  the  coats,  is  incomplete,  covering  the  posterior  sur- 
face, the  whole  of  the  upper  fundus,  a  small  extent  of  the 
lateral  surfaces,  and  a  variable  extent  of  the  lower  fundus. 
Xext  to  the  peritoneal  coat  is  a  fibrous  coat,  which  is  con- 
tinuous with  the  subperitoneal  connective  tissue  and  en- 
velops the  whole  bladder.  Beneath  this  is  the  muscular  coat 
in  three  superposed  layers  of  smooth  muscle  tissue  ;  the  ex- 
ternal layer  is  longitudinal,  the  middle  layer  is  transverse, 
and  the  internal  layer  is  reticular.  This  internal  reticular 
layer  is  separated  from  the  mucous  coat  by  the  submucous 


122 


or  fourtti  coat,  which  is  made  up  of  loose  connective  tissue 
with  a  rich  plexus  of  veins.  The  fifth  is  the  mucous  coat, 
the  mucous  membrane  of  the  bladder,  surmounted  by  a 
polymorphous  epithelium.  The  mucous  is  the  thinnest  of 
the  complete  coats  and  contains  no  mucous  follicles. 

The  maximum  thickness  of  the  walls  of  the  empty  nor- 
mal adult  bladder  is  about  a  quarter  of  an  inch  ;  but  when 
the  organ  is  in  a  state  of  moderate  distention  it  is  about  an 
eighth  of  an  inch. 

When  the  bladder  is  in  a  state  of  plenitude  its  mucous 
membrane  is  smooth ;  but  when  it  is  in  a  state  of  vacuity 
the  mucous  membrane  is  rugous,  except  at  the  trigone^ 
where  it  retains  its  smoothness  during  contraction  of  the 
bladder. 

The  color  of  the  vesical  mucous  membrane,  viewed  after 
death,  is  nearly  white  in  young  children,  it  is  grayish- 
white  in  adolescents  and  adults,  and  pinkish  in  old  men. 
Viewed  during  life  with  the  cystoscope,  in  adults  it  is  of  a 
distinctly  pink  hue,  with  here  and  there  small  arborescent 
blood-vessels. 

The  most  sensitive  part  of  the  vesical  mucous  membrane 
is  that  which  covers  the  trigone,  particularly  its  anterior  ex- 
tremity, corresponding  to  the  urethro-vesical  orifice. 

The  axatomical  characters  of  cystitis  vary  with  the 
site,  type,  stage,  and  termination  of  the  phlegmasia. 

In  acute  trachelocystitis  the  mucous  membrane  is  of  a 
deep-red  color,  highly  congested,  swollen,  velvety,  and  some- 
times softened  and  even  granular. 


123 

When  cystitis  arises  from  friction  by  a  calculus,  it  be- 
gins at  tbe  neck  and  trigone  of  the  bladder.  As  the  calcu- 
lus increases  in  size,  the  phlegmasia  extends  to  the  whole 
of  the  lower  fundus,  which  becomes  coated  with  a  layer  of 
pus  and  exfoliated  epithelium.  The  mucous  membrane  is 
sometimes  ulcerated  at  one  or  several  spots  when  the  stone 
is  irregular  in  shape  and  rough.  The  same  changes  occur 
from  the  irritation  of  uneven  foreign  bodies. 

Ulceration  and  even  perforation  of  the  bladder  coats 
have  arisen  from  the  prolonged  retention  of  a  catheter,  death 
occurring  from  the  entrance  of  urine  into  the  peritoneal 
cavity.     This  is  well  illustrated  in  the  exhibited  specimens. 

The  irritant,  whatever  it  may  be,  remaining  undisturbed, 
the  phlegmasia  sometimes  extends  to  the  submucous  coat, 
where  small  abscesses  form  and  discharge  their  contents 
into  the  bladder  cavity,  or  increase  in  size  and  point  infe- 
riorly  toward  the  rectum,  anteriorly  toward  the  pubes,  or 
laterally  or  posteriorly  toward  the  peritonaeum. 

In  most  cases  the  constant  spasmodic  contractions  of 
the  bladder  to  expel  its  contents  lead  to  increase  of  thick- 
ness of  the  muscular  coat  and  the  phlegmasia  to  sclerosis 
of  the  submucous  and  subperitoneal  coats  and  to  permanent 
contracture  of  the  viscus.  In  these  cases  the  reticular  or 
internal  layer  of  the  muscular  coat  is  sometimes  much 
thickened,  so  that  the  surface  of  the  bladder  cavity  is  very 
irregular,  rising  into  bold  columns  and  bands,  resembling 
those  of  the  heart  cavities ;  hence  their  name,  columnar 
bladders.  In  the  spaces  between  large  columns  the  mucous 
and  submucous  coats  are  forced  and  form  small  diverticula 


124 

capable  of  lodging  small  calculi  or  of  retaining  from  a  few 
drops  to  a  drachm  of  urine.  The  thin  walls  of  these  di- 
verticula sometimes  ulcerate  and  allow  their  contents  to 
escape  into  the  ambient  connective  tissue,  causing  pericys- 
titis, or  into  the  peritoneal  cavity.  These  "  spontaneous 
perforations "  of  the  bladder  were  first  well  described  in 
1835  by  the  late  Dr.  Mercier,  of  Paris.  In  much  rarer  in- 
stances the  diverticula  are  fewer,  but  are  large  and  con- 
stitute what  is  known  as  sacculation  of  the  bladder.  This 
will  be  described  under  the  head  of  ectatic  affections. 

Columnar  bladders  exist  mainly  in  cases  of  chronic  cys- 
titis from  obstruction  to  urination. 

The  slimy  urine  drawn  from  the  bladder  in  chronic  cys- 
titis has  led  to  the  erroneous  designation  of  this  affection 
as  "  catarrhal  fluxion,  or  catarrh  of  the  bladder,"  both  terms 
having  been  used  first  by  Lieutaud  in  the  eighteenth 
century.  The  term  catarrh  of  the  bladder  is  misleading 
and  tends  to  error  in  diagnosis  and  to  consequent  neglect 
of  regular  evacuative  catheterism  of  the  bladder.  Slimy, 
purulent  urine  is  the  result  of  fermentation  and  the  con- 
version of  the  urea  in  the  urine  into  ammonium  carbonate, 
which  possesses  the  property  of  rendering  pus  slimy,  and 
fermentation  occurs  when  the  urine  is  retained  in  the  blad- 
der by  a  material  obstacle  at  the  urethro-vesical  orifice  or 
in  the  urethra.  The  ammonia  is  not  only  the  irritant 
cause  of  the  suppuration,  but  the  active  agent  in  the  con- 
version of  the  greater  part  of  the  pus  into  slime.  Many 
writers  still  specialize  "  catarrh  of  the  bladder "  from 
chronic  cystitis.      It  is  known  that   chronic  cystitis  does 


125 

often  exist  without  the  urine  being  rendered  slimy,  but 
in  such  cases  there  is  no  hindrance  to  urination,  no  stag- 
nation, no  fermentation,  no  ammonia,  and  consequently 
no  slime.  The  slimy  urine  of  so-called  "  catarrh  of  the 
bladder"  probably  contains  very  little  mucus.  That  the 
slime  is  due  to  the  action  of  ammonia  upon  pus  is  demon- 
strable by  taking  pus  from  an  abscess,  diluting  it  with  water 
in  a  test-tube,  and  adding  liquor  ammonise.  In  a  few  mo- 
ments the  fluid  becomes  slimy  and  can  only  be  distinguished 
from  slimy  urine  by  its  color  and  by  its  not  containing  the 
elements  of  the  urine. 

Among  the  illustrative  specimens  exhibited  are  some  blad- 
ders whose  walls  have  increased  to  three  quarters  of  an  inch 
or  more  in  thickness.  These  specimens  were  taken  from  the 
bodies  of  men  that  had  died  after  long  suffering  from  uri- 
nary obstruction,  stagnation  of  urine,  and  consequent  cys- 
titis and  pyelonephritis.  They  are  nearly  all  good  examples 
of  interstitial  cystitis  superadded  to  myxocystitis.  In  most 
of  these  cases  the  bladder  is  capacious.  In  a  few  specimens 
the  bladder  is  shriveled  and  reduced  in  capacity  to  two  ounces 
or  even  to  an  ounce  and  a  half.  Yet  both  the  large  and  small 
illustrate  vesical  contracture,  neither  being  able  to  expel  any 
urine.  In  nearly  all  the  specimens  the  mucous  membrane  was 
thickened,  red,  and  its  vessels  were  gorged  with  blood.  In 
some  of  them  this  mucous  membrane  was  of  a  slaty  hue. 
In  one  it  was  mammillated,  oedematous.  These  bladders 
contained  a  slimy,  purulent,  chocolate-colored,  alkaline, 
foetid  urine.  In  nearly  all  of  them  the  ureters  and  renal 
pelves  were   distended  by  this   offensive  urine.     In  some 


126 


specimens  the  mucous  membrane  was  coated  with  slabs 
of  thick,  adhesive  pus,  miscalled  false  membranes  and 
diphtheritic  membranes.  One  of  these  specimens  showed, 
in  its  fresh  state,  the  whole  trigone  covered  with  a  thick 
layer  of  this  pus,  and  in  many  spots  the  mucous  mem- 
brane, of  a  dark-red  color,  appeared  where  the  softer  parts 
of  the  layer  of  pus  had  been  washed  away  by  a  stream 
of  water.  The  bladder  walls  are  three  quarters  of  an  inch 
in  thickness,  and  the  ureters  and  renal  pelves  are  much  di- 
lated. These  pathic  states  resulted  from  a  long-neglected 
urethral  stricture.  In  two  specimens  nearly  the  whole  of 
the  vesical  mucous  membrane  seems  to  have  been  destroyed 
by  tuberculosis  which  also  affected  both  kidneys. 

Gangrene  of  the  mucous  membrane  of  the  bladder  is  a 
rare  occurrence  even  from  violence.  It  has  happened  from 
the  supervention  of  acute  or  superacute  phlegmasia  in  cases 
of  chronic  cystitis,  from  unrelieved  complete  retention  in 
cases  of  stagnation  of  urine,  and  from  injury,  particularly  in 
bladders  containing  very  large  calculi. 

The  diagnosis  of  cystitis  is  arrived  at  after  ascertaining 
not  only  the  existence  of  this  phlegmasia,  but  its  cause,  site, 
type,  stage,  and  complications.  Frequent  desire  to  urinate 
and  pain  are  common  to  all  types  and  stages  of  cystitis, 
and  vary  only  in  degree.  These  two  symptoms  together 
suffice  to  establish  the  existence  of  cystitis.  To  ascertain 
the  cause  of  a  particular  attack  of  cystitis  is  sometimes  very 
difficult  and  requires  much  cross-examination  and  a  careful 
analysis  of  the  facts  elicited  from  the  patient.     Xo  further 


127 


reference  will  now  be  made  to  the  question  of  aetiology,  as 
it  has  already  been  fully  discussed. 

Acute  trachelocystitis  is  known  to  exist  when  urination 
becomes  very  frequent,  painful,  and  at  times  irrepressible ; 
the  urine,  passed  in  small  quantities,  even  in  drops,  being 
mixed  w^ith  blood  in  greater  or  less  proportion,  especially 
during  the  emission  of  the  last  drops,  when  the  pain  is  at  its 
height ;  this  urine  at  first  containing  a  considerable  propor- 
tion of  mucus,  derived  from  the  follicles  of  the  urethra,  and 
in  two  or  three  days  some  pus,  except  in  trachelocystitis 
due  to  the  extension  of  acute  urethritis,  when  pus  is  present 
in  the  urine  from  the  beginning  of  the  attack.  Trachelo- 
cystitis is  a  common  complication  of  prostatitis  and  of 
gonecystitis,  while  prostatitis  and  gonecystitis  are  rare  com- 
plications of  trachelocystitis.  Rectal  exploration  with  the 
finger  is  therefore  necessary  to  ascertain  the  existence  or 
non-existence  of  prostatitis  or  of  gonecystitis  in  any  case  of 
trachelocystitis. 

Subacute  trachelocystitis  is  known  to  exist  by  manifes- 
tations which  are  similar  to,  but  of  lesser  degree  than,  those 
of  the  acute  type.  The  introduction  of  a  rectangular  ex- 
ploring sound  is  necessary  to  determine  if  this  phlegmasia 
is  the  outcome  of  a  vesical  calculus  or  of  the  presence  of  a 
foreign  body. 

Chronic  trachelocystitis  is  usually  associated  with 
chronic  prostatitis  and  sometimes  with  chronic  urethritis. 
The  question  of  its  diagnosis  will  be  examined  in  connec- 
tion with  chronic  prostatitis  and  with  chronic  urethritis. 

The  diagnosis  of  subacute  general  myxocystitis,  pro- 


128 


voked  by  deviations  from  the  normal  standard  of  quantity 
and  quality  of  tlie  urinary  secretion,  is  arrived  at  througli 
the  history  of  the  affection  and  through  microscopical  ex- 
amination of  the  urine.  When  this  type  of  cystitis  be- 
comes chronic  and  is  attended  with  frequent  and  painful 
urination,  the  whole  bladder  is  contractured  and  its  capacity 
diminished.  This  is  ascertained  by  the  slow  injection, 
through  a  soft  catheter,  of  a  warm  antiseptic  solution,  the 
quantity  of  fluid  tolerated  indicating  the  capacity  of  the 
diseased  bladder.  In  some  cases  the  bladder  capacity  is 
reduced  to  four,  three,  two  ounces,  or  even  to  one  ounce. 
This,  however,  is  not  the  only  type  of  cystitis  in  which  con- 
tracture with  diminished  capacity  of  the  bladder  occurs. 
Such  an  untoward  complication  may  arise  in  cystitis  due  to 
nearly  all  the  causes  previously  named,  and  is  therefore  to 
be  taken  into  consideration  in  diagnosticating  cystitis  gen- 
erally. 

The  diagnosis  of  chronic  cystitis  developed  in  conse- 
quence of  obstructed  urination  requires  mechanical  explora- 
tion of  the  urethra,  urethro-vesical  orifice,  or  prostate,  and 
microscopical  examination  of  the  urine.  If  the  obstruction 
be  due  to  a  urethral  stricture,  it  is  revealed  by  the  use  of 
the  bulbous  bougie.  If  urethro-vesical  or  prostatic  obstruc- 
tion be  the  cause  of  the  stagnation  of  urine,  the  rectangular 
sound  demonstrates  the  existence  of  either ;  also  the  degree 
of  induration  of  the  bladder  and  of  enlargement  of  the 
bands  of  muscle  tissue  of  the  reticular  layer.  Gross  inspec- 
tion shows  the  urine  to  be  glairy,  slimy,  and  this  urine  con- 
verts red  litmus  paper  to  blue.     Microscopical  examination 


129 


of  tlie  urine  brings  into  view  innumerable  crystals  of  tbe 
ammonio-magnesian  phosphates,  pus-cells,  and  vesical  epi- 
thelium. When  no  urethral,  urethro -vesical,  or  prostatic 
obstruction  exists  and  the  urine  contains  creamy  pus  and 
no  slime,  the  origin  of  the  pus  is  presumably  pyelic, 
urethritis  being,  of  course,  excluded. 

Cystitis,  general  or  local,  arising  from  calculi,  from  in- 
juries, or  from  the  lodginent  of  foreign  bodies,  requires  for 
its  diagnosis  mechanical  exploration  of  the  bladder  and  mi- 
croscopical examination  of  the  urine. 

When  retention  of  urine  complicates  the  acute  or  the 
subacute  type  of  cystitis,  the  severe  pain  seated  in  the 
hypogastric  region  and  irradiated  to  the  abdominal  and 
lumbar  regions,  the  tenderness  and  tensive  swelling  in  the 
hypogastric  region,  the  straining  during  vain  efforts  to  uri- 
nate, the  flatness  under  percussion  in  the  region  of  the  dis- 
tended bladder,  render  the  diagnosis  of  this  complication 
comparatively  easy. 

When  complete  retention  occurs  in  chronic  cystitis  due 
to  stagnation  of  urine,  some  of  these  symptoms  are  ill-de- 
fined, while  others  of  a  graver  nature  are  manifested.  For 
instance,  the  pain  is  dull  but  continuous,  there  is  less  ten- 
derness and  little  or  no  tension  in  the  hypogastric  region, 
though  the  bladder  may  contain  much  more  urine  than  in 
the  case  of  retention  from  acute  cystitis,  and  may  project 
forward  like  a  gravid  uterus.  Retention  of  urine  in  the 
acute  cystitis  of  youth  and  middle  life  is  sudden  and 
causes  great  suffering ;  in  chronic  cystitis  from  prostatic 
obstruction  it  is  gradual  and  sometimes  undiscovered  until 


130 

the  lower  part  of  tlie  abdomen  begins  to  project  and  a 
sense  of  fullness  is  experienced  in  tbat  region  and  in  tbe 
rectum.  In  long-neglected  cases  the  patients  are  feeble  and 
emaciated,  able  to  take  but  little  food,  wliicb  is  often  vom- 
ited, the  pulse  is  small  and  weak,  sligbt  rigors  recur  every 
night,  the  body  is  covered  with  cold  sweat  having  a  urin- 
ous odor,  and,  in  point  of  fact,  the  kidneys  are  more  or 
less  damaged  by  the  action  of  a  column  of  purulent  urine 
which  is  retained  in  and  distends  the  ureter  and  renal  pelvis 
on  either  side. 

The  prognosis  of  cystitis  is  founded  upon  its  cause, 
type,  and  complications,  upon  the  previous  condition  of  the 
bladder,  upon  the  age,  constitutional  peculiarities,  and  gen- 
eral health  of  the  patient,  and  upon  the  degree  of  efficiency 
of  the  treatment. 

The  prognosis  is  favorable  in  cases  of  cystitis  arising 
from  the  first,  second,  and  third  groups  of  causes,  when  free 
from  complications  and  attacking  healthy  adults  ;  otherwise 
it  is  doubtful,  or  even  unfavorable,  for  the  phlegmasia  may 
become  unmanageable,  may  invade  the  upper  urinary  organs, 
and  prove  fatal  in  a  few  weeks,  or  even  in  a  few  days.  This 
is  sometimes  the  case  when  acute  or  superacute  phlegmasia 
attacks  a  bladder  that  has  long  been  diseased,  as  in  the 
chronic  cystitis  from  urethral  or  prostatic  obstruction. 

The  prognosis  is  unfavorable  in  cases  of  long-neglected 
cystitis  with  contracture  and  diminished  capacity  of  the 
bladder,  particularly  in  old  and  feeble  men.  Younger  sub- 
jects, free  from  urethral  obstruction,  withstand  the  inciden- 
tal suffering  much  longer,  and  their  condition  is  sometimes 


131 

greatly  improved  by  treatment.  In  some  of  tliese  younger 
subjects  it  is  possible  to  restore  tbe  normal  capacity  of  tbe 
bladder  even  after  the  lapse  of  a  year  from  the  beginning 
of  the  affection,  but  not  witliout  the  greatest  patience  and 
persistence  on  the  part  of  the  physician  and  the  greatest 
endurance  and  determination  on  the  part  of  the  patient. 

The  prognosis  is  unfavorable  in  cases  of  cystitis  due  to 
grave  disease  or  injury  of  the  nervous  centers.  The  pa- 
tients are  made  comparatively  comfortable  and  life  may  be 
prolonged  by  treatment,  but  the  cystitis  is  never  cured,  and 
renal  complications  finally  arise,  soon  to  prove  fatal. 

The  prognosis  is  more  favorable  in  cases  of  cystitis  due 
to  prostatic  obstruction  in  vigorous  elderly  men,  provided 
they  be  subjected  to  regular  catheterism  and  vesical  irriga- 
tions that  tend  to  arrest  fermentation  of  urine.  The  life  of 
such  patients  is  not  materially  shortened  by  this  incurable 
affection  if  the  local  treatment  be  faithfully  carried  out. 

The  conclusions  drawn  from  the  foregoing  study  of  the 
nature,  causes,  types,  complications,  and  consequences  of 
urocystitis  are : 

1.  This  affection  can  not  be  dealt  with  as  a  single  pathic 
entity. 

2.  Its  various  phases  and  the  general  condition  and  ao-e 
of  the  sufferer  are  all  to  be  taken  into  account  before  any 
plan  of  treatment  can  be  formed. 

3.  During  the  treatment  circumstances  are  likely  to 
arise  which  may  render  imperative  divers  modifications  in 
this  treatment,  or  its  temporary  suspension,  or  even  the 
substitution  of  palliative  for  curative  treatment. 


132 

VI. 

Cystitis  ;  its  Treatment. 

The  treatment  of  sufferers  from  cystitis  should  be  con- 
stitutional and  local.  The  general  indications  are  to  re- 
move the  original  cause,  to  relieve  pain,  to  shorten  the  pe- 
riod of  resolution  of  the  phlegmasia,  and  to  prevent  or  to 
combat  complications.  The  special  indications  vary  in  ac- 
cordance "with  the  exigencies  of  individual  cases.  The 
prime  requisite  to  the  rational  management  of  a  particular 
case  of  cystitis  is  the  proper  interpretation  of  its  phenome- 
na. This  is  possible  only  after  the  history  of  the  patient 
is  known  and  the  cause  of  the  phlegmasia  ascertained,  and 
a  close  analysis  is  made  of  its  subjective  and  objective 
symptoms.  An  accurate  diagnosis  can  have  no  other  foun- 
dation. 

Constitutional  Treatment. — When  a  subacute  cystitis 
is  traced  to  supersecretion  of  urine  of  low  specific  gravity, 
the  cause  of  the  polyuria  is  first  ascertained  and,  if  possible, 
removed  ;  then  the  cystitis  is  likely  to  cease.  For  instance, 
when  polyuria  is  due  to  temporarily  disturbed  innervation, 
the  re- establishment  of  the  nervous  equilibrium  is  sufficient 
to  effect  the  cessation  of  polyuria  and  thus  to  remove  the 
cause  of  the  cystitis.  This,  however,  is  hopeless  in  some 
cases  of  grave  disease  or  injury  of  nervous  centers,  as  it  is 
in  certain  serious  lesions  of  the  kidneys  where  the  polyuria 
is  irremediable.     In  some  cases  of  cystitis  due  to  persistent 


133 


polyuria,  opium  in  moderate  doses  has  the  double  eifect  of 
relieving  pain  and  of  lessening  the  urinary  secretion.  In 
other  cases  it  becomes  necessary  to  add  to  the  opium  either 
ergot  extract  or  gallic  acid. 

In  cases  of  cystitis  caused  by  diminished  secretion,  the 
urine  being  of  high  specific  gravity  and  acrid,  the  treat- 
ment should  be  such  as  to  cause  an  increase  in  the  quantity 
of  urine.  By  the  judicious  use  of  mild  alkaline  diuretics, 
such  as  the  citrate  of  soda  or  potash,  largely  diluted,  or  in- 
fusion of  uva  ursi,  decoction  of  triticum  repens,  etc.,  is  ac- 
complished the  indication  of  rendering  the  urine  bland,  and 
of  thus  causing  a  rapid  subsidence  of  the  cystitis. 

The  cases  of  cystitis  arising  indirectly  from  disturbance 
in  the  cutaneous  circulation  ordinarily  get  well  when  this 
circulation  is  re-established,  and  do  not  require  other  medi- 
cation than  such  as  may  render  the  urine  bland.  When, 
however,  the  cystitis  persists,  and  vesical  contracture  ensues 
in  any  of  the  varieties  of  the  first  group,  a  more  active  treat- 
ment is  necessary,  as  will  be  presently  stated. 

Cystitis  from  persistent  hyperlithuria  is  of  much  more 
frequent  occurrence  than  any  of  the  varieties  of  this  first 
group,  and  its  management  demands  close  attention.  This 
variety  of  cystitis  is  often  miscalled  irritability  of  the  blad- 
der, and  this  symptom  is  treated  with  opium,  belladonna, 
etc.,  and  the  phlegmasia  is  allowed  to  progress  until  perma- 
nent contracture  of  the  bladder  is  established.  This  cysti- 
tis is  as  amenable  to  treatment  and  to  cure  in  its  incipiency 
as  it  is  refractory  to  either  in  its  advanced  stages,  particu- 
larly after  contracture  of  the  bladder  is  confirmed. 


134 


If,  when  the  bladder  is  said  to  be  irritable,  the  urine  is 
examined  microscopically  and  found  to  contain  an  excess  of 
uric  acid,  and  treatment  for  hyperlithuria  is  at  once  insti- 
tuted, normal  urination  is  soon  restored  and  all  symptoms 
of  beginning  cystitis  disappear.  Patients,  affected  with  cys- 
titis due  to  hyperlithuria  are  necessarily  hyperlithsemic, 
and  this  is  consequent  upon  dyspepsia  and  hepatic  engorge- 
ment. In  such  cases  there  is  habitual  costiveness,  and  with 
this  headaches,  muscular  pains,  and  other  symptoms  of 
ptomainal  or  leucomainal  toxaemia.  The  treatment  should 
therefore  be  directed  to  the  restoration  of  the  digestive 
function  and  to  the  remedy  of  the  consequences  of  its  im- 
pairment. For  these  ends  the  first  desideratum  is  free 
catharsis ;  then  daily  aperient  medicines  and  the  so-called 
hepatics,  such  as  small  doses  of  podophyllin,  leptandrin, 
irisin,  colocynth,  and  nux  vomica,  combined.  At  the  same 
time  should  be  prescribed  alkaline  waters,  such  as  those  of 
Yichy,  from  the  Celestins  spring,  six  ounces  four  times 
daily,  between  meals,  for  two  weeks  or,  at  most,  three  weeks. 
When  there  is  a  very  abundant  precipitate  of  uric  acid, 
causing  greater  distress  than  usual,  nothing  seems  to  act  so 
quickly  as  ten  grains  of  salicylate  of  sodium,  largely  di- 
luted, four  times  daily  for  two  or  three  days  only ;  as  such 
doses  are  not  long  tolerated  by  the  stomachs  of  most  pa- 
tients, their  continuance  beyond  that  time  is  not  wise.  This 
should  precede  the  administration  of  the  Vichy  water. 
Five-grain  or  even  ten-grain  doses  of  phenacetin  sometimes 
promptly  relieve  the  muscular  pains  which  so  often  accom- 
pany hyperlithsemia. 


135 


During  this  treatment  and  for  three  or  four  weeks  there- 
after the  patient  should  abstain  from  eating  starches  and 
sugars,  or  use  them  very  sparingly,  especially  at  the  even- 
ing meal.  Abstention  from  all  articles  of  food  tending  to 
cause  flatulency,  and  from  malt  liquors,  cider,  sweet  wines, 
etc.,  is  essential,  as  they  are  known  to  be  so  often  hurtful 
to  the  process  of  digestion  in  the  cases  under  considera- 
tion. Sufficient  bodily  exercise,  promotion  of  the  cuta- 
neous functions  by  frequent  ablutions  and  frictions,  and 
clothing  suited  to  the  state  of  the  weather,  constitute  the 
remainder  of  the  hygienic  management. 

A  medication  and  hygienic  precautions  such  as  have 
just  been  described  are  likely  to  nip  in  the  bud  a  cystitis 
which  would  otherwise  become  very  distressing  and  lead  to 
transitory,  and  finally  to  permanent  contracture  with  steno- 
sis of  the  bladder.  But  contracture  of  the  bladder,  even  of 
many  months'  standing,  is  not  necessarily  hopeless  and  is 
often  cured ;  but  this  requires  the  greatest  patience  on  the 
part  of  the  physician  and  of  the  sufferer. 

The  local  treatment  consists  in  the  use  of  medicinal 
and  mechanical  means.  When  acute  cystitis  is  accompanied 
with  transitory  contracture,  which  is  a  state  of  rigidity  of 
the  muscular  coat  of  the  bladder  preceded  by  frequent  and 
painful  spasmodic  contractions  especially  at  the  close  of 
each  act  of  urination,  a  brisk  saline  cathartic  should  first  be 
administered,  then  half  a  dozen  leeches  should  be  applied 
to  the  perinseum  and  as  many  to  the  hypogastrium.  As 
soon  as  the  gorged  leeches  drop,  hot  fomentations  should 


136 

be  applied  to  the  hypogastrium  and  continued  for  two  or 
three  days.  This  local  depletion  is  of  much  advantage  in 
young  robust  subjects,  but  should  be  omitted  in  those  whose 
health  has  already  been  impaired  or  those  who  are  known 
to  be  intolerant  of  bloodletting  in  any  form.  Two  or  three 
liberal  doses  of  opium  may  be  necessary  to  relieve  the  pain 
incident  to  the  acute  phlegmasia,  and  diluent  drinks  should 
be  given  throughout  the  treatment.  A  hot  hip  bath,  of  five 
minutes,  every  night  is  often  very  advantageous.  No  in- 
strument should  be  introduced  into  the  bladder  except  in 
the  case  of  retention  of  urine,  which,  however,  is  of  ex- 
tremely rare  occurrence  in  these  cases.  After  a  few  doses 
of  belladonna  extract,  a  quarter  of  a  grain  four  times  daily 
for  two  or  three  days,  the  sensitiveness  of  the  bladder  is 
lessened  and  it  allows  itself  to  be  distended  by  the  urine 
rendered  bland  by  the  diluent  beverages.  Resolution  of  the 
phlegmasia  begins  and  the  tonic  spasms  of  the  bladder  cease, 
so  that  in  the  course  of  a  few  more  days  the  patient  is  able 
to  retain  his  urine  several  hours,  and  is  soon  well. 

In  chronic  cystitis  with  contracture,  if  there  are  not  very 
much  thickening  and  induration  of  the  bladder  walls  conse- 
quent upon  interstitial  cystitis,  mechanical  as  well  as  consti- 
tutional treatment  is  required,  the  indications  being  to 
remedy  the  phlegmasia  and  to  restore  to  the  bladder  its 
normal  suppleness  and  capacity.  The  constitutional  treat- 
ment must  be  used  as  an  indispensable  adjuvant  to  the  me- 
chanical treatment,  which  would  otherwise  be  fruitless. 

The  inordinate  irritability  of  the  bladder  and  the  accom- 
panying distressing  and  unduly  frequent  urination  incident 


137 

to  cystitis  witli  contracture,  react  upon  tlie  nervous  system 
to  the  extent  of  seriously  disturbing  sleep  and  of  rendering 
the  patient  excessively  fretful.  He  is  constantly  on  the 
alert  for  the  moment  to  arrive  when  it  is  time  to  urinate, 
and  ever  ready  to  clutch  any  object  that  may  serve  as  a  ful- 
crum for  his  straining  efforts.  His  face  then  becomes  livid 
and  intense  suffering  is  thereon  depicted.  At  the  close  of 
the  act  of  urination  he  throws  himself  upon  his  bed  ex- 
hausted, but  not  always  to  sleep,  and  even  then  often  dreams 
of  his  distress.  This  scene  is  renewed  every  hour,  half -hour, 
or  even  every  quarter  of  an  hour.  His  skin  is  harsh  and 
inactive,  his  digestion  is  soon  impaired,  his  appetite  van- 
ishes, his  intestinal  dejecta  are  hard  and  scanty,  and  he  is 
in  no  slight  degree  under  the  influence  of  leucomainal  in- 
toxication. Such  is  a  true  picture  of  the  worst  cases.  It 
is  therefore  wise  to  endeavor  to  remedy  these  several 
morbid  states  before  they  attain  this  high  state  of  develop- 
ment. 

The  first  prescription  should  be  for  a  cathartic.  The 
next,  for  a  nightly  dose  of  twenty  or  thirty  grains  of  sodium 
bromide,  with  the  object  of  procuring  sleep  and  of  prolong- 
ing the  intervals  of  urination.  Then  thrice  daily  five  min- 
ims of  tincture  of  the  chloride  of  iron  with  a  grain  of  qui- 
nine. Other  medicinal  agents  that  may  be  indicated  should 
be  used  with  due  regard  to  the  state  of  the  digestive  func- 
tion, and  not  given  beyond  the  point  of  tolerance.  For  in- 
stance, diluents  should  not  be  continued  more  than  four 
days,  to  be  replaced  by  balsamics,  which  in  some  cases  act 
so  favorably  as  modifiers  of  the  urine  ;   the  balsamics  in 


138 

their  turn  to  be  discontinued  in  favor  of  some  diluent.  Bel- 
ladonna and  opium,  and,  for  a  change,  hyoscyamia,  not  more 
than  one  two-hundredth  of  a  grain  thrice  daily,  are  not 
generally  well  tolerated  longer  than  four  days.  Such  are 
the  agents  required  for  the  constitutional  treatment,  but  they 
should  be  used  with  discretion  and  judgment,  otherwise  the 
desired  effect  is  not  likely  to  be  obtained. 

Gradual  Hydraulic  Dilatation  of  the  Contract- 
URBD  Bladder. — The  mechanical  treatment  consists  in 
slow,  gradual,  and  progressive  hydraulic  dilatation  of  the 
bladder,  and  is  effected  in  the  manner  presently  to  be  de- 
scribed. 

An  eight-ounce,  pear-shaped  India-rubber  bag  with  noz- 
zle and  stop-cock  is  filled  with  a  warm  solution  of  mercuric 
chloride  (1  to  10,000),  with  the  addition  of  thirty  grains  of 
boric  acid,  ten  minims  of  spirit  of  gaultheria,  and  half  an 
ounce  of  glycerin.  A  curved  gum  catheter,  No.  9  English 
scale,  is  introduced  into  the  bladder  and  all  the  contained 
urine  is  allowed  to  flow  and  is  measured.  Suppose  the  quan- 
tity of  urine  thus  drawn  to  be  one  ounce ;  the  nozzle  of  the 
India-rubber  bag  is  thrust  into  the  distal  end  of  the  cathe- 
ter, and,  by  very  gently  compressing  the  bag,  as  much  of 
the  fluid  is  slowly  thrown  in  as  the  bladder  can  tolerate  with- 
out too  much  pain.  The  fluid  is  then  allowed  to  escape 
through  the  catheter  and  is  measured.  In  this  manner  the 
capacity  of  the  bladder  is  determined.  It  may  be  of  an 
ounce  and  a  half  or  two  ounces.  A  second  injection  at  the 
same  sitting  determines  the  degree  of  distensibility  of  the 


139 


bladder,  for  if,  after  a  very  slight  increase — two  or  three 
drachms  over  the  amount  of  the  first  injection — the  fluid 
drawn  is  tinged  with  blood,  the  operator  knows  that  the 
bladder  has  been  distended  beyond  its  abnormally  restricted 
dimensions,  that  a  slight  violence  has  been  inflicted  upon 
its  mucous  coat,  and  that  he  should  desist  from  further  at- 
tempts at  distending  the  bladder  during  the  sitting,  and 
throw  in  only  one  ounce  of  fluid  at  a  time,  simply  to  soothe 
and  cleanse  the  bladder,  until  the  eight  ounces  are  exhausted. 
On  the  next  day,  the  patient  being  under  the  influence  of 
belladonna  or  of  hyoscyamia,  the  process  of  injection  and 
dilatation  is  repeated.  It  may  be  that  no  gain  is  made  over 
the  maximum  distention  of  the  previous  day,  or  even  that 
there  is  a  loss,  the  bladder  being  less  tolerant  than  before, 
so  that  not  over  one  ounce  of  fluid  can  be  injected.  This 
often  happens  during  the  early  part  of  the  treatment,  but 
should  not  discourage  the  operator,  for  on  the  third  day's 
sitting  there  may  be  a  gain  sufiicient  to  more  than  make  up 
for  the  loss.  With  the  exception  of  such  retrogressions  and 
the  occasional  occurrence  of  slight  hgemorrhages,  the  dila- 
tation is  progressive  from  day  to  day,  though  the  increase 
on  some  days  can  be  measured  only  by  the  drop,  while  on 
other  days  it  is  by  the  drachm,  but  later  by  the  ounce,  and 
in  the  course  of  five  or  six  weeks  the  bladder  sometimes  tol- 
erates eight,  ten,  or  twelve  ounces  of  fluid.  When  this  stage 
is  reached  the  injections  are  repeated  every  second  day, 
twice  a  week,  and  finally  only  once  a  week,  until  the  cystitis 
is  cured. 

A  very  important  point  to  which  the  attention  of  the 


140 


physician  should  be  directed  is  the  habit  that  some  pa- 
tients, affected  with  cystitis  and  contracture,  form  of  urinat- 
ing, so  to  speak,  by  the  clock.  Unless  this  habit  be  soon 
broken,  the  case  may  well  be  regarded  as  hopeless.  The 
example  to  be  given  is  a  fair  illustration  of  this  point.  A 
patient,  for  the  relief  of  whose  suffering  cystotomy  had 
been  proposed,  said  that  he  had  also  been  advised  to  uri- 
nate often  so  as  to  keep  his  bladder  empty  as  long  as  pos- 
sible. He  therefore,  for  several  months,  employed  most  of 
his  time  in  watching  a  clock,  and  whether  or  not  he  had  any 
desire  to  urinate  he  did  so  regularly  every  fifteen  minutes. 
It  was  very  difficult  to  convince  him  that  he  was  commit- 
ting a  grave  error,  but  as  he  was  daily  getting  worse  he 
finally  consented  to  pay  no  further  attention  to  the  minutes 
by  the  clock  or  watch,  and  in  a  few  days  retained  his  urine 
half  an  hour,  three  quarters,  and  one  hour,  and  in  the 
course  of  three  weeks  the  mechanical  dilatation  of  the  blad- 
der was  carried  from  two  ounces  to  ten  ounces.  He  was 
then  able  to  retain  his  urine  four  hours.  This  urine,  from 
being  purulent,  bloody,  and  offensive,  became  clear  and 
normal. 

For  vesical  irrigation  and  dilatation  in  chronic  cystitis 
with  contracture,  sundry  other  solutions  beside  that  already 
mentioned  may  be  employed,  such  as  of  phenol,  permanga- 
nate of  potassium,  permanganate  of  zinc,  acetate  of  lead, 
acidulated  water,  etc. 

It  may  be  interesting  to  note  some  of  the  many  differ- 
ent substances  that  have  been  employed  for  vesical  injec- 
tions during  the  past  hundred  years.     Chopart  seems  to 


141 


have  been  among  the  first  to  resort  to  vesical  irrigations 
for  the  cure  of  cystitis,  although  the  early  lithotoniists, 
among  them  Franco,  used  warm  vesical  irrigations  as  part 
of  the  after-treatment  of  lithotomy  to  cure  any  lingering- 
cystitis,  and  although  in  the  beginning  of  the  eighteenth 
century  Pierre  Desault,  of  Bordeaux,  had  used,  in  calculous 
cystitis,  injections  of  the  mineral  water  of  Bareges.  Cho- 
part  at  first  made  use  of  simple  warm  water,  then  of  barley 
water,  and  afterward  of  acetate  of  lead  dissolved  in  water. 
Later,  in  England  and  France,  others  used  flax-seed  water, 
soot  water,  tar  water,  calomel  susj)ended  in  an  emulsion  of 
acacia  gum,  wine,  normal  urine,  etc.  Still  later,  copaiba 
balsam  in  emulsion,  carbonic-acid  gas,  solutions  of  hypo- 
sulphite of  sodium,  bromide  of  potassium,  iodide  of  potas- 
sium, tincture  of  iodine,  corrosive  chloride  of  mercury, 
chloride  of  sodium,  carbonate  of  sodium,  nitrate  of  silver, 
sulphate  of  zinc,  alum,  tannin,  strychnine,  morphine,  qui- 
nine, salicylic  acid,  resorcin,  methylaniline,  peroxide  of 
hydrogen,  divers  mineral  waters,  etc.,  with  varying  but 
mostly  bad  results,  partly  because  no  attempt  had  been 
made  to  gradually  dilate  the  contractured  bladder. 

It  is  often  advantageous  to  change,  from  time  to  time, 
the  formulae  of  the  fluids  to  be  injected,  but  the  essential  is 
to  bear  in  mind  the  indications  of  curing  the  phlegmasia 
and  of  restoring  to  the  bladder  its  normal  suppleness  and 
capacity. 

This  method  of  gradual  hydraulic  dilatation  of  the  blad- 
der, employed  by  Civiale  and  others  of  his  time,  appears  to 
have  been  soon  set  aside  by  many  who  have  been  allured  by 


142 


the  quicker  and  seemingly  more  promising  method  of  sudden 
dilatation  aided  by  artificially  induced  general  anaesthesia. 
The  quick  method,  which  does  serious  violence  to  the  blad- 
der, is  generally  unsafe,  often  dangerous,  and  seldom  if  ever 
successful.  The  slight  benefit  it  very  exceptionally  confers 
is  of  short  duration,  and  the  old  symptoms  soon  return  in  a 
more  aggravated  form  than  before.  The  advocacy  of  sudden 
distention  of  the  bladder  with  a  solution  of  nitrate  of  silver, 
thirty  grains  to  the  ounce,  is  even  more  unwarrantable. 
This  rash  procedure  has  been  adopted  by  many  who  have 
regretted  it,  for  when  the  patients  have  survived  the  vio- 
lence and  cauterization,  their  bladders  have  become  perma- 
nently and  incurably  contractured,  stenosed,  and  thickened 
from  the  consequent  interstitial  phlegmasia. 

Nitrate  of  Silver  in  Cystitis. — In  obstinate  cystitis 
nitrate  of  silver  is  unquestionably  a  valuable  therapeutic 
agent  when  used  at  the  right  time  and  in  solutions  of  suita- 
ble strength,  but  very  strong  solutions  not  only  fail  to  cure 
but  do  serious  mischief.  After  the  bladder  has  been  gradu- 
ally dilated  to  eight  or  ten  ounces  and  the  same  amount  of 
urine  is  retained  without  causing  pain  or  haemorrhage,  if 
this  urine  is  still  purulent,  a  weak  solution  of  nitrate  of 
silver  may,  with  much  advantage,  be  employed  for  irriga- 
tion every  four  or  five  days.  A  grain  of  crystallized 
nitrate  of  silver  is  dissolved  in  eight  ounces  of  distilled 
water,  then,  after  having  drawn  off  all  the  urine  contained 
in  the  bladder  and  washed  it  twice  with  pure  water,  two  in- 
jections of  four  ounces  each  are  rapidly  made  with  the 


143 


nitrate-of -silver  solution.  In  four  or  five  days  the  process 
is  repeated,  but  tlie  quantity  of  nitrate  of  silver  is  doubled. 
After  this  the  solution  is  gradually  increased  in  strength  to 
three,  four,  eight,  and  sixteen  grains  of  nitrate  of  silver  to 
the  eight  ounces  of  warm  water,  and  it  is  very  rarely  neces- 
sary to  increase  the  strength  of  the  solution  to  thirty-two 
grains  to  the  eight  ounces,  for,  after  eight  or  ten  sittings,  all 
the  good  that  may  be  expected  is  accomplished.  Guyon, 
of  Paris,  uses  the  nitrate-of-silver  solution  by  way  of  in- 
stillations of  ten,  fifteen,  twenty,  or  thirty  drops  of  the 
strength  of  from  five  to  sixty  grains  to  the  ounce,  once  and 
sometimes  twice  daily,  principally  in  trachelocystitis. 

As  far  back  as  the  latter  part  of  the  last  century  strong- 
solutions  of  nitrate  of  silver  were  used  in  the  treatment  of 
cystitis,  from  fifteen  to  sixty  grains  to  the  ounce  of  distilled 
water.  In  some  instances,  instead  of  the  silver  salt,  corro- 
sive chloride  of  mercury  was  used  in  the  same  strength  and, 
it  is  said,  with  the  same  effect.  Long  afterward  Trousseau 
began  to  use,  for  vesical  injection,  the  mercuric  chloride, 
but  only  at  the  rate  of  about  a  quarter  of  a  grain  to  the 
ounce.  Bretonneau  was  a  strong  partisan  of  vesical  injec- 
tions, and  finally  employed  nitrate  of  silver  in  cystitis,  but 
his  solutions  did  not  exceed  a  quarter  of  a  grain  to  the 
ounce.  In  1842  Mercier  revived  the  use  of  strong  solutions 
of  nitrate  of  silver,  beginning  with  fifteen  grains  and  gradu- 
ally increasing  to  sixty  grains  to  the  ounce,  and  this  treat- 
ment was  adopted  by  Ricord  and  others,  and  is  to  this  day 
employed. 

The  advocates  of  strong  solutions  declare  the  weak  solu- 


144 


tions  to  be  wortUess  because,  they  say,  tlie  urine  decom- 
poses the  nitrate  of  silver,  converting  it  into  an  inert 
cbloride,  and  tliey  further  say  that  thirty  minims  of  urine 
suffice  to  decompose  a  grain  of  nitrate  of  silver.  When  the 
precaution  is  taken  of  carefully  washing  the  bladder  imme- 
diately before  making  the  injection,  surely  enough  urine 
does  not  enter  by  the  ureters  to  decompose  a  grain  or  a 
quarter  of  a  grain  of  nitrate  of  silver  rapidly  thrown  in,  and 
it  should  be  remembered  that  two  injections  are  made  in 
quick  succession  within  a  minute  or  before  the  sixteen 
minims  of  urine  which  it  receives  per  minute  can  possibly 
act  upon  the  silver  salt.  Even  in  the  event  of  polyuria,  if 
the  urine  entering  the  bladder  should  be  increased  to  thirty 
minims  or  to  sixty  minims  a  minute,  which  would  be  half 
a  minim  in  the  one  case  and  one  minim  a  second  in  the 
other  case,  it  would  not  be  sufficient  to  decompose  the 
weakest  of  the  proposed  solutions,  for  to  inject  four  ounces 
of  fluid  in  the  bladder  requires  not  more  than  ten  or  twelve 
seconds  of  time,  the  increase  in  the  saline  not  being  neces- 
sarily proportionate  with  the  watery  element.  Besides,  as 
a  proof  that  the  weak  solutions  of  nitrate  of  silver  do  act 
upon  the  mucous  membrane  of  the  bladder  before  the  salt 
can  be  decomposed  by  the  chlorides  as  well  as  by  the  acid 
phosphates,  the  injections  are  almost  invariably  followed  by 
a  burning  pain,  which  lasts  from  twenty  to  thirty  minutes, 
and  by  frequent  and  urgent  desire  to  urinate  for  two  or 
three  hours.  Without  there  being  enough  urine  in  the 
bladder  to  decompose  the  nitrate  of  silver,  the  ejected  solu- 
tion has  a  milky  appearance,  indicating  its  conversion  into 


145 


a  cUoride.  The  action  of  nitrate  of  silver  is  primarily 
upon  the  epithelium.  A  solution  of  moderate  strength  co- 
agulates the  albumin  of  the  superficial  epithelial  layer,  and 
in  so  doing  is  decomposed  into  an  insoluble  chloride.  But 
a  very  strong  solution  is  likely  to  act  upon  all  the  epithelial 
layers,  and  even  to  penetrate  more  deeply  and  coagulate  the 
albumin  and  gelatin  of  the  fibrous  layer  of  the  mucous 
membrane  before  it  is  decomposed,  and  the  irritation  it 
causes  leads  to  interstitial  cystitis.  Here,  then,  lies  the 
main  objection  to  the  use  of  strong  solutions. 

The  repeated  application  of  strong  solutions  of  nitrate 
of  silver  to  mucous  membranes  has  been  demonstrated  to 
cause  induration  not  only  of  the  mucous  membranes  them- 
selves but  of  their  underlying  connective  tissue.  These 
membranes  soon  lose  their  elasticity,  being,  as  it  were, 
tanned,  and  often  sj)oken  of  as  leathery.  This  condition  of 
sclerosis  has  been  observed  on  a  large  scale  in  the  fauces 
among  patients  that  had  been  treated  during  the  great  craze 
of  thirty-five  years  ago  for  cauterizing  the  human  fauces  on 
the  most  trivial  complaint  of  "  sore  throat,"  and  was  com- 
monly termed  the  nitrate-of-silver  throat,  from  which  they 
never  recovered.  A  similar  condition  has  been  observed 
during  life  in  the  urethra,  from  frequent  applications  of 
strong  solutions  of  nitrate  of  silver  and  other  irritants. 
The  bladder  may  recover  from  the  effects  of  a  single  injec- 
tion of  a  strong  solution  of  nitrate  of  silver,  but  when  the 
strong  injections  are  several  times  repeated  in  accordance 
with  the  directions  given  by  those  who  advocate  their  em- 
ployment, the  delicate  mucous  membrane  of  this  organ  must 
10 


146 

suffer  mucli  more  tlian  other  mucous  membranes  that  are 
not  the  recipients  of  such  an  irritating  excrement  as  the 
urine,  and  whose  outlets  are  free  and  broad. 

Cystotomy,  infkapubic  and  suprapubic,  has  been 
frequently  performed  during  the  past  forty  years  for  the 
cure  of  obstinate  cystitis  with  contracture  of  the  muscular 
coat  of  the  bladder  uncomplicated  by  the  presence  of  a 
tumor,  stone,  or  foreign  body,  or  by  prostatic  obstruction. 
The  alleged  effect  of  this  operation  is  that  it  affords  com- 
plete drainage  of,  and  rest  to,  the  bladder,  and  therefore 
cures  the  cystitis  and  contracture. 

The  analysis  of  a  considerable  number  of  reported  cys- 
totomies for  chronic  cystitis  uncomplicated  with  vesical 
tumors,  stones,  or  foreign  bodies,  shows  that  the  relief  af- 
forded by  the  drainage  was  only  temporary,  and  that  they 
had  failed  to  cure  the  cystitis  and  contracture. 

It  is  not  desirable  nor  is  it  possible  to  keep  open  the 
neck  of  the  bladder  more  than  three  or  four  weeks.  Cica- 
trization takes  place  within  that  period,  notwithstanding  the 
use  of  dilating  instruments,  and  the  natural  action  of  the 
vesical  neck  is  restored  and  prevents  the  urine  from  escap- 
ing involuntarily.  The  insertion  through  the  external 
wound  and  the  long  retention  of  a  large  tube  does  not  pre- 
vent cicatrization  of  the  urethro-vesical  wound,  and  this 
tube  acts  injuriously  as  a  foreign  body.  There  is  no  cura- 
tive power  in  rest  and  drainage  of  the  bladder  in  the  case 
of  cystitis  and  contracture.  The  temporary  drainage,  in 
the  most  obstinate  and  distressing  cases,  may  sometimes  be 


147 

of  advantage  as  preparatory  and  adjuvant  to  the  hydraulic 
dilatation  of  the  bladder  without  which  no  permanent  cure 
need  be  expected,  and  this  dilatation  should  be  employed 
a  few  days  after  the  perineal  cystotomy.  The  fluid  for 
irrigation  is  heated  from  105°  to  110°  F.,  and  thrown 
in  very  slowly,  one,  two,  or  three  ounces  at  a  time,  un- 
til a  pint  is  used.  This  process  is  repeated  once  each 
day  until  eight,  ten,  or  twelve  ounces  can  be  injected  at 
once,  but  before  this  is  accomplished  the  wound  will  have 
healed. 

In  the  case  of  suprapubic  cystotomy  a  fistula  has  been 
kept  patent  for  months,  and  in  some  instances  for  years, 
but  without  curing  the  cystitis  or  the  contracture. 

The  prescription  of  long  rest  to  the  bladder  in  these 
cases  does  not  seem  rational,  since  it  is  well  known  that  the 
prolonged  immobilization  of  any  part  so  surely  leads  to  its 
permanent  contracture.  The  muscular  walls  of  the  bladder 
need  to  be  exercised  in  cases  of  cystitis  with  contracture 
which  has  not  become  permanent,  and  this  exercise  is  at- 
tainable by  hydraulic  expansion,  which  gradually  restores  to 
the  bladder  its  normal  suppleness  and  capacity. 

The  treatment  of  acute  trachelocystitis,  due  to  the 
extension  of  acute  urethritis,  consists  in  recumbency,  a  light 
regimen,  the  administration  of  diluent  drinks  to  render  the 
urine  bland,  the  use  of  belladonna  and  opium  by  mouth  or 
rectum,  of  hot  fomentations  to  the  hypogastric  region,  and 
of  daily  warm  baths.  For  ordinary  cases  this  treatment 
suffices  to  induce  resolution  in  the  course  of  a  week  or  ten 


148 


days.  Balsamics  are  often  prescribed,  but  only  serve  to 
disturb  digestion.  Other  cases  attended  witb  great  pain 
and  dysuresis  require  local  depletion,  sucb  as  may  be  effect- 
ed by  leeching  the  perinseum,  and  the  substitution  of  cold 
for  warm  applications,  the  cold  being  applied  within  the 
rectum  by  way  of  ice  suppositories.  jS'o  instruments  should 
be  introduced  into  the  urethra  except  in  the  event  of  reten- 
tion of  urine.  In  these  severer  cases  it  is  necessary  to  give 
free  doses  of  alkalies,  such  as  the  bicarbonate  of  sodium, 
thirty  or  forty  grains,  largely  diluted,  four  times  daily  for 
three  or  four  days,  and  to  increase  the  doses  of  belladonna 
and  opium.  Though  the  pain  and  urgent  and  frequent  uri- 
nation diminish  under  this  treatment,  resolution  is  frequently 
incomplete,  and  the  affection  becomes  chronic.  It  is  in 
these  chronic  cases  that  Guyon's  method  of  instillations  of 
nitrate- of -silver  solution  is  of  the  greatest  service  ;  but  this 
will  be  detailed  in  the  discussion  of  chronic  prostatitis. 

The  treatment  of  cystitis  due  to  injuries  of  the  bladder 
will  be  stated  in  connection  with  the  subject  of  traumatic 
affections  of  the  urinary  organs. 

Treatment  of  Calculous  Cystitis. — When  cystitis  is 
caused  by  the  presence  of  a  calculus  or  of  a  foreign  body,  it 
is  sometimes  necessary  to  prepare  the  bladder  for  the  removal 
of  either  irritant.  The  bladder  may  be  spasmodically  con- 
tracted around  the  calculus  or  the  foreign  body  to  such  a  de- 
gree as  to  gravely  interfere  with  the  play  of  the  instruments 
introduced  for  the  destruction  or  the  removal  of  the  in- 
truder.    In  such  a  case  the  preparation  begins  with  the  ad 


149 


ministration  of  a  few  free  doses  of  belladonna  and  opium 
for  two  or  three  days.  During  this  time  the  bladder  is 
daily  irrigated  with  a  warm,  soothing  antiseptic  solution, 
dilating  it  gradually  as  much  as  necessary  for  the  safe  de- 
struction of  the  calculus  or  the  extraction  of  the  foreign 
body ;  either  operation  being  successfully  performed,  the 
after-treatment  consists  in  daily  irrigations  tending  to  cure 
the  phlegmasia  and  to  restore  the  bladder  to  its  normal 
state. 

In  the  management  of  cystitis  due  to  obstruction 
BY  LOCAL  URETHRAL  STENOSIS  the  physiciau  is  guided  by  the 
character  and  caliber  of  the  stricture,  by  its  complications, 
and  by  the  general  physical  state  of  the  patient.  If  the 
stricture,  though  very  narrow,  is  free  from  complications 
and  susceptible  of  expansion,  its  gradual  dilatation  is  at  once 
begun  and  practiced  every  third  or  fourth  day.  As  soon  as 
the  urethral  canal  is  thus  sufficiently  enlarged  at  the  strict- 
ured  point  to  render  urination  moderately  free,  the  acts  are 
less  painful,  less  frequent,  the  bladder  is  soon  emptied,  and 
the  cystitis  begins  to  subside,  to  be  well,  as  a  general  rule, 
when  the  urethra  is  dilated  to  its  normal  caliber.  When, 
however,  the  stricture  is  not  dilatable  beyond  three  or  four 
millimetres,  it  should  be  cut  longitudinally  from  within,  and 
a  catheter  introduced  to  draw  o£E  the  purulent  urine  and 
to  permit  the  thorough  cleansing  and  disinfection  of  the 
bladder.  The  catheter  is  afterward  used  for  every  act  of 
urination,  and  the  bladder  washed  once  each  day  until  there 
are  no  more  signs  of  cystitis.    If  there  happens  to  be  vesical 


150 


contracture,  gradual  hydraulic  dilatation  becomes  neces- 
sary. When  internal  urethrotomy  is  contra-indicated  by 
reason  of  the  extreme  narrowness  of  a  stricture  seated  in 
the  scrotal  or  perineal  region,  especially  if  there  be  a  uri- 
nary fistula  or  an  abscess,  the  operation  of  external  perineal 
urethrotomy  should  be  performed  without  delay,  to  give 
free  vent  to  the  urine ;  but  this  urine  should  be  drawn  off 
by  means  of  a  large  catheter  passed  through  the  wound, 
and  the  bladder  thoroughly  cleansed  once  or  twice  daily. 
If  there  is  no  serious  complication  toward  the  uj^per  uri- 
nary organs,  the  cystitis  is  likely  to  be  cured,  or  nearly  so, 
before  the  external  wound  is  fairly  healed. 

The  cystitis  of  elderly  men  affected  with  prostatic 
enlargement  requires  unremitting  attention  from  the  earliest 
period  of  its  development,  because  of  the  grave  conse- 
quences that  arise  from  neglect  to  relieve  the  bladder  of 
the  stagnant  urine  which  so  surely  undergoes  fermentation 
with  the  conversion  of  its  urea  into  carbonate  of  ammoni- 
um, and  the  extension  of  the  consequent  phlegmasia  to  the 
whole  of  the  vesical  mucous  membrane  and  even  to  its  under- 
lying fibrous  coat.  This  cystitis  is  generally  of  slow  develop- 
ment. i\t  first  the  urine  contains  very  little  pus,  only  the 
lower  fundus  of  the  bladder  being  affected.  The  amount  of 
residual  urine  may  not  exceed  an  ounce,  but  this  residuum 
gradually  increases  until  the  bladder  is  abnormally  distended. 
The  urine  is  then  ammoniacal,  slimy,  and  foetid,  and  urination 
is  unduly  frequent  and  very  painful.  If  before  the  cystitis 
reaches  this  state  of  development  the  catheter  is  used  once 


151 


or  twice  daily  and  tte  bladder  is  properly  cleansed,  further 
fermentation  is  prevented  and  the  plilegmasia  subsides. 
But  if  tbe  cystitis  has  already  extended  to  the  whole 
vesical  mucous  membrane,  proper  measures  should  be  taken 
to  check  the  ammoniacal  conversion  of  the  urea  of  the 
urine  and  to  counteract  its  ill  effects.  The  amount  of 
urea  metamorphosed  into  ammonium  carbonate  is  not  less 
than  two  per  cent.,  or  nearly  ten  grains  to  the  ounce  of 
urine.  This  percentage  of  ammonium  carbonate  is  quite 
sufficient  to  excite  cystitis,  to  act  upon  the  albumin  of  the 
pus-corpuscles,  and  to  saponify  the  fats  of  the  pus,  the 
result  of  these  changes  being  the  slime,  miscalled  ropy 
mucus,  which  is  sometimes  so  tenacious  that  it  can  not  be 
extracted  through  an  ordinary  catheter.  There  are  two 
ways  of  relieving  a  bladder  gorged  with  tenacious  slime. 
One  is  to  convert  the  carbonate  into  an  acetate  of  ammoni- 
um by  throwing  in  largely  diluted  acetic  acid,  thus  liberating 
the  fats  and  liquefying  the  slime,  which  then  assumes  a 
milky  appearance ;  the  other  is  to  remove  the  slime  by  as- 
piration through  a  large-sized  catheter. 

The  bladder  is  then  to  be  emptied  by  means  of  an  ordi- 
nary catheter  five  or  six  times  every  twenty -four  hours  and 
thoroughly  cleansed  with  an  antiseptic  solution  once  and 
sometimes  twice  daily,  night  and  morning.  About  ten 
ounces  of  fluid  at  a  temperature  of  105°  to  110°  F.  may  be 
employed  for  this  purpose,  one  third  to  be  injected  and 
three  successive  injections  to  be  made  at  each  sitting.  The 
substances  dissolved  may  be  varied  from  time  to  time — 
boric  acid  with  the  corrosive  chloride  of  mercury,  phenol, 


152 

permanganate  of  potassium,  etc. — and  continued  as  long  as 
the  urine  is  alkaline.  When  the  urine  resumes  its  normal 
acidity  the  injections  need  not  be  used  oftener  than  twice  a 
week,  but  the  use  of  the  catheter  should  not  be  abandoned. 
When  the  urine  contains  phosphates  in  great  abundance, 
two  grains  of  acetate  of  lead  to  the  ounce  of  warm  water, 
with  two  minims  of  acetic  acid,  may  be  used  with  good 
effect,  there  being  a  double  decomposition  and  the  forma- 
tion of  a  soluble  acetate  of  the  bases,  and  of  an  insoluble 
phosphate  of  lead.  Water  acidulated  with  nitric  or  hydro- 
chloric acid,  two  or  three  minims  to  the  ounce,  may  also  be 
used  with  advantage.  These  two  means  constitute  the 
prophylaxis  of  phosphatic  stone. 

One  of  the  gravest  of  the  consequences  of  the  cystitis 
of  elderly  men  suffering  from  prostatic  obstruction  is  con- 
tracture with  diminished  capacity  of  the  bladder ;  this,  hap- 
pily, is  of  comparatively  rare  occurrence,  while  contracture 
with  increased  vesical  capacity  is  the  rule.  These  patients 
are  tormented  by  constantly  painful  and  unduly  frequent 
urination,  and,  if  allowed,  would  introduce  the  catheter 
every  half -hour,  for  they  suffer  all  the  pangs  of  acute  reten- 
tion of  urine,  and  their  bladders  bear  very  little  if  any  arti- 
ficial hydraulic  distention.  Though  they  are  the  most  hope- 
less of  all  cases,  their  suffering  is  often  alleviated  by  free 
doses  of  belladonna  and  opium,  and  by  one  or  two  daily  in- 
jections of  warm  water  rendered  denser  by  the  addition  of 
glycerin  and  some  salt  of  sodium  or  potassium. 

The  physician  is  sometimes  called  upon  to  minister  to 
the  suffering  caused  by  complete  retention  of  urine,  another 


153 


grave  complication  of  the  cystitis  arising  from  stagnation 
of  urine  due  to  prostatic  obstruction.  His  duty  in  such  a 
case  is  to  ascertain  the  degree  of  enlargement  of  the  pros- 
tate and  the  exciting  cause  of  the  occlusion  of  the  urethro- 
vesical  orifice.  He  may  learn,  by  patient  cross-examination, 
that  the  sufferer  had  been  exposed  to  inclement  weather,  or 
had  committed  some  excess,  or  that  his  rectum  had  not 
been  relieved  for  several  days,  etc.  He  may  also  learn  how 
long  since  the  bladder  had  been  emptied,  whether  the  pa- 
tient or  any  one  else  had  used  a  catheter,  and  if  so  what 
kind  of  catheter ;  if  catheterism  had  been  unsuccessful,  how 
many  times  it  had  been  tried  ;  whether  haemorrhage  had  fol- 
lowed the  attempts  made  to  enter  the  bladder,  and  whether 
he  had  had  any  chills  after  the  catheterisms.  Then  he  should 
make  a  general  examination  of  the  case  to  ascertain  the 
condition  of  the  patient  and  the  degree  of  distention  of  the 
bladder.  If  he  finds  the  patient  suffering  much  constitu- 
tionally from  his  ailment  he  should  not  at  once  resort  to 
catheterism,  but  first  administer  a  broth,  a  stimulant,  and 
an  opiate,  and  finally  an  enema  to  empty  the  rectum.  In 
an  hour  or  two  he  may  select  a  suitable  catheter,  introduce 
it  and  draw  off  only  a  pint  of  urine,  two  hours  after  this 
another  pint,  and  so  on  every  two  or  three  hours  until  the 
bladder  is  empty.  The  dangerous  procedure  of  precipi- 
tately evacuating  the  overdistended  bladder  of  elderly  men 
has  already  been  pointed  out,  but  an  example  will  be  given 
later.  The  best  instrument  for  ordinary  use  is  a  No.  9 
English  curved  gum  catheter.  If  on  account  of  a  longi- 
tudinal rent  in  the  prostate  the  point  of  the  catheter  is 


154 


arrested  and  by  gentle  manipulation  can  not  be  made  to 
enter  tbe  bladder,  the  instrument  should  be  withdrawn  and 
armed  with  a  properly  curved  metal  stylet  and  reintro- 
duced after  the  manner  of  William  Hey,  which  consists  in 
carrying  the  instrument  to  the  point  of  obstruction  and  in 
then  withdrawing  the  stylet,  at  the  same  time  pushing  in 
the  catheter  seized  with  the  left  thumb  and  index.  The 
suddenly  increased  curve  changes  the  direction  of  the  vesi- 
cal extremity  of  the  instrument,  and  the  bladder  is  thus  en- 
tered. If  no  urine  flows  it  is  probably  because  the  eye  of 
the  catheter  is  obstructed  by  a  clot  of  blood  which  can  be 
driven  out  by  injecting  quickly  through  the  instrument  an 
ounce  or  two  of  water.  It  sometimes  happens  that  this 
method  of  catheterism  fails.  Then  the  invaginated  catheter 
of  Mercier  may  be  substituted  with  the  fairest  prospect  of 
success.  This  ingenious  contrivance  has  many  times  obvi- 
ated the  necessity  for  puncture  of  the  bladder,  which  is  to 
be  regarded  as  an  evil  and  performed  for  temporary  relief 
only,  in  case  suitable  catheters  can  not  be  procured  for 
many  hours.  The  invaginated  catheter  consists  of  two 
catheters — one  metallic,  the  other  non-metallic.  The  first 
or  female  part  is  a  thin-walled  No.  10  English  silver  cathe- 
ter, eleven  inches  long,  very  slightly  curved,  and  having  in 
its  concavity,  about  half  an  inch  from  the  point,  an  oval  eye 
five  eighths  of  an  inch  in  length  and  three  sixteenths  in 
breadth.  From  the  vesical  extremity  of  the  eye  is  an  in- 
clined plane,  which  is  lost  in  the  floor  of  the  opening  at  a 
distance  of  a  quarter  of  an  inch,  serving  to  tilt  up  the  point 
of  the  male  part.     This  male  part  is  a  flexible  but  firm 


155 

"  gum  "  catheter,  No.  V  English,  eighteen  inches  long,  fit- 
ting loosely  in  the  lumen  of  the  female  part,  and  having  a 
single  eye  an  eighth  of  an  inch  from  its  point.  The  man- 
ner of  using  the  invaginated  catheter  is  to  introduce  the 
male  into  the  female  part  as  far  as  the  eye  of  the  female 
part,  then  to  pass  the  instrument  as  far  as  the  obstacle  and 
engage  the  point  of  the  metallic  part  in  the  false  route,  and 
finally  to  project  the  male  part,  which  will  override  the  false 
route  thus  blocked  and  enter  the  bladder.  The  female  part 
can  then  be  withdrawn  and  the  male  part  left  in  as  long  as 
may  be  required  ;  this  is  the  reason  for  the  increased  length 
of  the  male  part. 

In  case  of  multiple  false  routes  in  the  prostatic  region 
and  of  failure  of  all  methods  of  catheterism,  the  patient  is 
rendered  insensible  by  ether,  or,  better,  by  nitrous-oxide  gas, 
and  is  placed  in  the  lithotomy  position.  A  grooved  steel 
stafE  is  then  introduced  into  the  urethra  as  far  as  possible, 
a  median  incision  is  made  in  the  perinseum,  the  membranous 
urethra  is  laid  open  longitudinally  with  a  bistoury,  the  left 
index  finger  is  passed  as  far  as  the  bladder  to  serve  as  a 
guide  for  a  broadly  grooved  director ;  the  finger  is  then 
withdrawn,  and,  with  the  guidance  of  the  director,  a  deep 
downward  cut  is  made  with  a  long-bladed  beaked  bistoury 
in  the  median  line  through  the  base  of  the  prostate,  includ- 
ing the  neck  of  the  bladder.  Before  withdrawing  the  di- 
rector a  soft  India-rubber  tube  of  not  less  than  ten  'milli- 
metres in  diameter  is  introduced  and  retained  in  position 
for  forty-eight  hours.  Meanwhile  the  bladder  is  irrigated 
twice  or  thrice  daily.     After  the  withdrawal  of  the  tube. 


156 


the  same,  or  one  sliglitly  smaller,  is  used  once  or  twice 
daily  to  cleanse  the  bladder,  though  the  urine  may  be 
flowing-  involuntarily.  In  the  course  of  three  or  four  weeks 
the  false  routes  and  the  external  wound  heal  by  granula- 
tion, and  ordinary  catheterism  may  be  employed  to  empty 
the  bladder. 

Vesical  Haemorrhage. — When  the  overdistended  blad- 
der has  been  precipitately  emptied  and  an  abundant  haemor- 
rhage has  ensued,  this  viscus  should  not  again  be  allowed 
to  become  distended,  and  means  should  be  promptly  taken 
to  arrest  the  haemorrhage.  In  such  a  case  may  be  adminis- 
tered twenty-minim  doses  of  fluid  extract  of  ergot  every 
two  or  three  hours,  or  ten  grains  of  gallic  acid  dissolved  in 
glycerin,  or  the  same  quantity  of  quinine  dissolved  in  dilute 
sulphuric  acid.  Vesical  injections  of  cold  water,  slightly 
acidulated  with  acetic  acid,  may  be  made  after  each  evacuat- 
ing catheterism.  Then  it  is  essential  that  the  bladder  be 
kept  empty.  So  long  as  the  urine  is  much  in  excess  of  the 
effused  blood,  this  blood  retains  its  fluidity  ;  but  when  the 
blood  is  in  excess,  coagulation  rapidly  takes  place  and  the 
bladder  is  soon  distended  with  dense  clots  which  can  not 
be  extracted  until  they  are  broken  up  and  removed  by  as- 
piration through  a  large  catheter. 

A  vigorous  farmer,  seventy  years  of  age,  was  seen  in 
consultation  at  his  home  on  the  last  day  of  June,  1891,  on 
account  of  profuse  vesical  haemorrhage  due  to  his  having 
suddenly  emptied  his  overdistended  bladder  flve  days  be- 
foi'e  when  he  had  ridden  forty  miles  in  a  light  carriage. 
The  bladder  was  filled  with  clots  and  distended  to  the  level  of 


157 


the  umbilicus.  Notwithstanding  the  existence  of  prostatic 
obstruction,  catheterism  was  easy,  but,  after  a  little  bloody 
urine  had  escaped,  a  clot  occluded  the  gum  catheter.  A 
metallic  catheter,  ten  millimetres  in  diameter,  was  substi- 
tuted and  moved  in  different  directions  to  break  up  the 
clots,  several  ounces  of  which  were  aspirated  by  means  of 
Bigelow's  instrument.  A  lithotribe  was  then  used  to 
further  break  up  the  clots,  and  these  were  likewise  aspi- 
rated. After  this  several  injections  of  diluted  vinegar  were 
made  and  the  patient  allowed  to  rest  and  sleep  for  three 
hours,  when  catheterism  was  again  employed,  but  with  a 
smaller  instrument,  which  was  not  this  time  obstructed, 
and  a  pint  of  bloody  urine  drawn.  After  several  cold  irri- 
gations with  ten  per  cent,  of  vinegar  the  ejected  fluid  con- 
tained very  little  blood  and  no  more  clots.  The  haemor- 
rhage gradually  lessened  and  ceased  on  the  third  day.  It 
had  lasted  eight  days  in  all.  Meanwhile  evacuative  cathe- 
terism had  been  practiced  every  five  hours.  In  a  week  the 
family  physician  wrote  that  the  patient  was  in  good  condi- 
tion, though  he  had  been  troubled  with  polyuria,  which 
necessitated  the  more  frequent  use  of  the  catheter,  and  that 
the  cystitis  was  under  control,  the  bladder  being  daily  irri- 
gated.    The  patient  is  at  this  date  in  excellent  condition. 

Treatment  of  the  Cystitis  due  to  Disease  or  Injury 
OF  THE  Great  Nerve  Centers. — The  discussion  of  the 
treatment  of  cystitis  will  now  be  closed  with  some  hints 
respecting  the  management  of  the  cystitis  which  arises  from 
stagnation  and  fermentation  of  urine  due  to  disease  or  injury 
of  the  great  nerve  centers.     In  patients  who  survive  grave 


158 

lesions  of  tlie  brain  or  of  the  spinal  cord  for  weeks  or  months 
it  lias  long  since  been  observed  that  frequently  the  im- 
mediate cause  of  death,  is  traceable  to  consecutive  lesions 
of  the  urinary  organs,  such  as  cystitis,  ureteritis,  pyelo- 
nephritis, calculous  formation,  etc.,  all  arising  from  stag- 
nation of  urine  in  the  bladder,  whose  sensibility  is  blunted 
or  even  destroyed,  owing  to  the  nerve-center  lesion,  and 
that  when  early  attention  is  given  to  the  impaired  urinary 
organs  while  the  primary  disease  or  injury  is  undergoing 
treatment,  the  life  of  the  patient  is  prolonged  and  his 
suffering  lessened.  The  needed  treatment  is  simple  and 
effective,  so  far  as  the  urinary  organs  are  concerned. 
Very  soon  after  a  patient  becomes  paraplegic  his  bladder 
ceases  to  act  and  rapidly  fills  with  urine ;  therefore  it 
should  be  artificially  emptied  at  once,  if  it  is  not  over- 
distended.  So  long  as  the  urine  is  clear  and  of  acid  reac- 
tion, simple  evacuative  catheterism,  practiced  at  regular 
intervals,  suflBces  to  prevent  stagnation  and  cystitis.  But 
when  the  urine  is  already  turbid  and  alkaline  the  bladder 
should  be  irrigated  once  or  twice  daily  with  suitable  solu- 
tions. This  plan  of  treatment  has  been  cunent  in  Bellevue 
Hospital  for  the  past  twenty-six  years,  and  it  is  believed 
that  the  lives  of  many  patients  have  thus  been  prolonged 
for  months  and  even  for  years.  Experienced  surgeons 
know  so  well  how  commonly,  in  depressed  fractures  of  the 
skull,  the  bladder  becomes  distended  with  urine,  that  the 
first  direction  they  give  to  their  aids  is  to  empty  the 
patient's  bladder,  with  the  object  of  preventing  overdis- 
tention  and  cystitis. 


159 
yii. 

PROSTATITIS    AND    BULBO-URETHRAL    ADENITIS. 

Prostatitis — pUegmasia  of  the  vesical  prostatic  body — 
may  begin  and  end  in  the  glandular  part  (parenchymatous 
prostatitis)  ;  it  may  thence  extend  to  the  interstitial  connect- 
ive and  muscular  framework  of  the  prostate  body  (diffuse 
prostatitis),  or  it  may  occur  in  the  peripheral  connective 
tissue  (periprostatitis).  The  phlegmasia  may  be  superacute, 
acute,  subacute,  or  chronic. 

Causes. — Prostatitis  may  arise  from  urethritis,  from  ve- 
nereal excesses,  from  the  contact  of  some  irritant  with  the 
mucous  membrane  of  the  prostatic  region  of  the  urethra, 
such  as  often  repeated  strongly  astringent  injections  in  the 
treatment  of  "gonorrhoea,"  from  external  injury,  from  vio- 
lent catheterism,  or  from  exposure  to  cold  and  dampness. 
The  superacute  and  acute  types  are  of  very  rare  occurrence, 
and  generally  caused  by  the  extension  of  acute  or  superacute 
urethritis  into  the  prostatic  ducts  and  follicles,  whence  the 
phlegmasia  diffuses  itself  into  the  interstitial  substance,  and 
sometimes  extends  into  the  peripheral  connective  tissue. 
This  is  sometimes  excited  by  the  so-called  abortive  treat- 
ment of  "  gonorrhoea  "  by  the  injection  of  a  strong  solution 
of  nitrate  of  silver.  The  subacute  type  affects  at  first  the 
parenchyma  only,  but  later  invades  the  interstitial  substance, 
and  may  gradually  pass  into  the  chronic  type. 

These  several  types  of  phlegmasia  are  apt  to  leave  the 


160 


prostate  in  a  very  seriously  damaged  state,  sucli  as  follows 
destruction  of  a  considerable  proportion  of  tlie  glandular 
substance,  induration,  shriveling,  etc. ;  still  tbere  are  many 
cases  that  end  in  resolution  without  apparent  injury  to  any 
part  of  the  organ. 

The  chief  symptoms  of  the  acute  types  of  prostatitis  are, 
in  the  beginning,  a  sense  of  weight  in  the  perineal  region ; 
increased  frequency  and  difficulty  of  urination ;  pain  ref- 
erable to  the  urethro-vesical  orifice  ;  and  a  sense  of  fullness 
in  the  rectum,  with  tenesmus.  When  the  affection  is  con- 
secutive to  urethritis  the  patient  notices  a  cessation  of  the 
discharge,  which  is  ordinarily  the  case  in  most  of  the  conse- 
quences of  urethritis.  In  the  course  of  two  or  three  days 
all  these  sensations  are  greatly  intensified.  The  rectal 
tenesmus  is  much  increased,  and  the  urgent  desire  to  empty 
the  bowel  is  ungratifiable  by  reason  of  the  prostatic  swell- 
ing. The  dysuresis  and  stranguria  become  very  distress- 
ing ;  finally,  ischuria  supervenes,  and  there  is  much  pain  in 
the  lumbar  region  and  along  the  course  of  the  sciatic  and 
anterior  crural  nerves,  from  the  fast-accumulating  urine  in 
the  bladder.  Any  pressure  in  the  perinseum  gives  a  sharp 
pain,  which  is  acutely  felt  at  the  extremity  of  the  urethra, 
such  as  that  experienced  when  a  calculus  comes  in  contact 
with  the  urethro-vesical  orifice. 

Trachelocystitis  is  ahnost  always  associated  with  pros- 
tatitis, and  two  other  unwelcome  guests,  gonecystitis  and 
orchitis,  sometimes  intrude  themselves  to  further  distress 
the  sufferer. 

The  little  urine  passed  spontaneously  before  the  advent 


161 


of  iscliuria  is  acrid,  higli-colored,  purulent,  and  at  times 
bloody. 

Exploration  -witli  the  finger  introduced  into  the  rectum 
reveals  much  swelling,  tension,  heat,  and  hardness  of  the 
prostate,  which  nearly  fills  the  lower  end  of  the  rectum. 
The  slightest  pressure  made  with  this  finger  causes  great 
suffering  to  the  patient,  the  pain  extending  to  the  glans 
penis. 

The  diagnosis  of  acute  prostatitis  is  based  upon  the 
analysis  of  the  symptoms  detailed  above  and  upon  the  rectal 
exploration. 

Progress. — Acute  prostatitis  generally  resolves  in  the 
course  of  three  or  four  weeks,  but  sometimes  suppurates. 
The  superacute  type  almost  always  suppurates. 

The  subacute  type  is  slow  in  resolving,  and  sometimes 
ends  in  an  abscess  or  in  multiple  abscesses  of  very  gradual 
development. 

In  the  superacute  and  acute  types  the  advent  of  sup- 
puration may  be  predicted  when  the  occurrence  of  rigors 
and  febrile  reaction  is  followed  by  throbbing  pains  in  the 
rectum  and  perinieum.  The  pus  may  find  an  outlet  in  the 
bladder,  in  the  urethra,  in  the  rectum,  or  may  point  forward 
toward  the  perinseum  or  backward  toward  the  peritoneal 
cavity.  The  relations  of  the  prostate  to  the  bladder  render 
possible  the  discharge  in  this  viscus  of  an  abscess  pointing 
superiorly  and  posteriorly.  The  directions  most  commonly 
taken  by  the  pus  are  toward  the  urethra  and  toward  the 
rectum.    When  the  abscess  opens  on  the  floor  of  the  urethra 

by  several  small  orifices,  and  freely  discharges  its  contents, 
11 


162 


no  liarm  ensues,  but  when  there  happens  to  be  a  large  open- 
ing, the  dangers  of  destruction  of  the  whole  prostate  by  the 
urine,  and  of  consequent  pyosapraemia,  are  great. 

A  case  illustrating  this  point  occurred  in  1864  at  Bellevue 
Hospital.  The  patient,  a  young  man,  was  suffering  from 
retention  of  urine  consequent  upon  a  prostatic  abscess.  For 
his  relief  a  silver  catheter  was  introduced,  but  met,  in  the 
prostatic  region,  with  an  obstruction,  which  was,  however, 
overcome,  the  incidental  pressure  causing  the  instrument  to 
suddenly  advance  about  an  inch,  when  two  ounces  of  creamy 
pus  flowed,  but  the  bladder  was  not  entered.  From  that 
time  the  bladder  relieved  itself  spontaneously.  Symptoms 
of  pyosaprsemia  supervened,  and  the  patient  died  in  two 
weeks.  The  necropsy  revealed  a  ragged  opening  in  the 
floor  of  the  urethra  leading  to  a  large  cavity,  with  sloughy 
walls,  containing  stale  urine  and  pus.  The  whole  prostate 
was  disorganized. 

When  the  abscess  points  toward  the  rectum,  digital  ex- 
ploration reveals  fluctuation  in  that  situation  ;  the  prostate, 
hard  and  tender  during  the  periods  of  increase  and  stasis 
of  the  phlegmasic  process,  is  now  soft  and  little  sensitive 
to  the  touch,  one  lobe  or  both  lobes  being  in  this  state  of 
suppuration. 

In  periprostatitis,  which  is  caused  most  frequently  by 
violent  catheterism,  the  abscess  often  points  forward  toward 
the  perinaeum.  The  abscess  very  rarely  points  backward. 
The  great  danger  in  such  cases  lies  in  its  breaking  into  the 
peritoneal  cavity.  When  the  bladder  is  empty  the  recto- 
vesical fold  of  the  peritonaeum  descends  to  about  half  an 


163 


incli  of  the  base  of  the  prostate,  but  as  the  bladder  fills,  the 
peritonseum  ascends  with  it  so  that  the  antero-posterior 
space  uncovered  by  peritonaeum  is  doubled  in  extent.  In 
some  instances,  however,  as  shown  by  the  specimens  ex- 
hibited, the  peritonfeum  reaches  and  even  overlaps  the  base 
of  the  prostate.  These  facts  are  sufficient  to  account  for 
the  occasional  occurrence  of  peritonitis  in  cases  of  acute 
prostatitis. 

In  the  treatment  of  the  acute  types  of  prostatitis,  local 
antiphlogistic  measures  should  be  promptly  adopted,  the 
main  indications  being  to  prevent  suppuration  and  hasten 
resolution.  Antiphlogistic  treatment  is,  however,  applica- 
ble only  during  the  stages  of  increase  and  stasis.  Later, 
that  is  to  say,  when  there  are  already  signs  of  softening 
and  suppuration,  this  treatment  is  of  no  avail,  and  may 
even  be  harmful. 

!  Z;'  In  any  case  of  acute  prostatitis  the  first  inquiry  of  the 
physician  should  relate  to  the  condition  of  the  bladder.  If 
he  finds  retention  of  urine,  he  should  lose  no  time  in  reliev- 
ing the  distended  bladder.  Unless  the  bladder  is  kept 
empty,  any  mode  of  treatment  tending  to  favor  resolution 
of  the  phlegmasic  process  in  the  prostate  must  inevitably 
fail,  for  the  distended  bladder  mechanically  impedes  the 
venous  circulation  in  its  vicinity.  Catheterism  in  cases  of 
swollen  prostates  is  often  very  difficult  and  requires  the  ut- 
most caution  and  gentleness.  The  use  of  metallic  catheters 
is  unjustifiable  in  the  vast  majority  of  cases  of  retention  of 
urine  from  acute  prostatitis.  The  safest  and  most  efficient 
instruments  for  this  purpose  are  the  soft,,  curved,  so-called 


164 


gum  catheters,  not  larger  than  No.  9  of  the  English  scale. 
Such  catheterism  is  ordinarily  required  every  five  or  six 
hours  for  at  least  a  week.  Recumbency  is,  of  course,  en- 
joined. 

After  the  intestinal  tract  has  been  emptied,  the  rectum 
should  be  thoroughly  washed.  Immediately  after  the  cleans- 
ing process  three  or  four  leeches  should  be  applied  to  that 
part  of  the  rectum  underlying  the  prostate.  This  can  be 
conveniently  accomplished  with  the  aid  of  the  leech-tube 
devised  by  Dr.  James  S.  Hughes,  of  Dublin.  This  tube  is 
much  better  than  those  of  Begin,  Henderson,  and  Craig. 
The  following  is  Dr.  Hughes's  description  of  his  leech-tube  : 

"  The  instrument  .  .  .  consists  of  a  curved  gum-elastic 
or  gutta-percha  tube,  of  about  six  inches  in  length,  open  at 
one  extremity,  closed  at  the  other,  the  latter  being  rounded 
off  and  inverted  or  bell-shaped,  and  perforated  with  two  or 
more  conical  holes  capable  of  enabling  the  leeches  to  do 
their  duty  but  not  to  escape  through.  The  lesser  curve  of 
the  tube  is  grooved  or  concave  externally.  The  following 
is  the  mode  in  which  the  instrument  should  be  used  :  The 
patient  having  been  placed  in  the  kneeling  posture,  the 
surgeon  should  pass  the  forefinger  of  his  left  hand,  pre- 
viously well  oiled,  into  the  rectum  with  a  gentle  I'otatory  mo- 
tion, until  it  has  reached  the  infiamed  prostate ;  he  then 
should  take  with  his  right  hand  the  leech-tube,  previously 
oiled  and  furnished  with  from  one  to  four  leeches,  as  the  case 
might  be,  and  pass  it  along  the  curved  dorsal  aspect  of  the 
left  forefinger  to  the  exact  spot  where  the  leeches  ought 
to  be  applied,  the  left  forefinger  acting  as   a  director  to 


165 


the  leech-tube,  and  forming  with  it,  as  it  were,  one  instru- 
ment, the  concave  surface  of  the  tube  traversing  and  adapt- 
ing itself  to  the  convex  surface  of  the  finger.  By  this 
simple  contrivance  leeches  can  be  brought  and  kept  in  con- 
tact with  the  rectal  surface  of  the  prostate  without  danger 
of  their  escaping  from  the  instrument  into  the  intestine, 
on  the  one  hand,  or  of  the  tube  becoming  blocked  with 
feculent  matter  on  the  other."  These  leech-tubes  of  Dr. 
Hughes's  have  lately  been  made  of  glass. 

There  may  be  circumstances  forbidding  the  application 
of  leeches  to  the  rectal  mucous  membrane.  In  such  cases, 
ten  or  twelve  leeches  may  be  applied  to  the  perineal  and 
anal  regions,  the  effect  of  either  mode  of  leeching  being 
to  disgorge  the  prae-prostatic  plexus  of  veins  and  thus  re- 
lieve the  blood  stasis  in  the  capillary  vessels  of  the  prostate. 

When  it  is  judged  that  a  sufficient  amount  of  blood  has 
escaped  after  the  dropping  of  the  leeches,  the  rectum  should 
be  cleansed  and  then  packed  with  ice,  which  should  be  re- 
newed as  fast  as  it  melts,  means,  such  as  the  introduction 
of  a  gum-elastic  tube,  being  provided  for  the  escape  of  the 
water  if  it  does  not  flow  freely  during  the  insertion  of  new  ice 
suppositories.  This  ice  treatment  should  be  continued  two, 
three,  or  four  days,  according  to  the  necessities  of  the  case. 
The  relief  afforded  by  the  cold  is  great,  and  enables  the  pa- 
tient to  obtain  much  refreshing  sleep.  During  the  day  the 
ice  is  renewed  every  half -hour  if  need  be,  but  once  every 
two  hours  in  the  night  generally  suffices,  the  patient  wak- 
ing to  ask  for  a  renewal  of  the  ice  suppositories.  Should 
it  not  be  possible  to  continue  the  use  of  ice  by  the  rectum. 


166 


an  India-rubber  bag  filled  with  ice  could  be  applied  to  the 
perinfeum,  and  the  benefit  of  dry  cold  thus  obtained. 

During  these  three  or  four  days  catharsis  should  be  kept 
up  by  drachm  doses  of  sulphate  of  sodium,  dissolved  in  three 
ounces  of  hot  water,  every  four  hours.  Tartarized  anti- 
mony was  formerly  given  in  doses  of  one  eighth  of  a  grain 
every  four  hours,  but  this  can  now  be  judiciously  replaced 
by  diaphoretics  that  cause  less  depression  than  the  anti- 
monial  salt. 

To  insure  diuresis,  from  forty  to  sixty  grains  of  bicar- 
bonate of  sodium  should  be  given  in  six  ounces  of  water 
three  and  even  four  times  daily.  This  alkali,  in  such  cases, 
acts  as  an  antiphlogistic  and  as  a  diluent  counteracting  the 
acridity  of  the  urine.  A  full  dose  of  morphine  by  the 
mouth  or  hypodermically  serves  the  purposes  of  relieving 
pain  and  inducing  sleep.  The  diet  should  be  restricted  to 
broths  and  bread  and  milk. 

If  resolution  begins  within  a  week  from  the  onset  of 
the  phlegmasia,  it  may  be  promoted  by  hot  enemata,  hot 
fomentations  to  the  hypogastric  and  perineal  regions,  and  a 
hot  hip  bath  of  five  minutes'  duration  every  night.  Inter- 
nally, five  grains  of  chloride  of  ammonium  may  be  given 
four  times  daily,  and  mild  saline  aperients  administered 
every  morning.  Under  favorable  circumstances,  in  the 
course  of  two  or  three  weeks  from  the  beginning  of  resolu- 
tion the  prostate  nearly  regains  its  normal  condition.  Re- 
constituents  and  a  generous  diet  are  then  indicated. 

When  resolution  fails  and  suppuration  occurs,  the  sooner 
the  pus  is  allowed  free  outlet  the  better.     If  the  pus  is  dis- 


167 


charged  into  the  urethra,  the  greatest  care  should  be  taken 
to  prevent  the  urine  from  entering  the  abscess  cavity.  The 
patient  should  not  be  allowed  to  urinate  spontaneously,  but 
the  catheter  introduced,  as  before,  every  five  or  six  hours, 
for  two  or  three  weeks  after  the  first  gush  of  pus,  so  as  to 
give  time  for  contraction  of  the  cavity  and  healing  by 
granulation  from  the  bottom.  If  the  pus  points  toward  the 
rectum,  a  Sims  speculum  should  be  introduced  and  a  sufii- 
ciently  free  incision  made  into  the  abscess,  whose  cavity 
should  be  well  disinfected  and  loosely  packed  with  antisep- 
tic gauze.  If  the  cavity  is  very  small,  it  may  be  left  to 
granulate  without  packing.  When,  as  in  periprostatitis,  the 
abscess  points  toward  the  perinseum,  if  fluctuation  is  de- 
tected by  perineal  palpation,  a  central  perineal  incision  an- 
swers the  purpose  of  emptying  it ;  but  if  the  indications  of 
suppuration  are  entirely  by  rectal  exploration,  a  crescentic 
incision,  followed  by  careful  dissection  between  the  urethra 
and  rectum,  is  required  to  safely  reach  the  purulent  focus, 
after  whose  evacuation  and  cleansing  with  peroxide  of  hy- 
drogen solution  the  same  dressing  may  be  made  as  in  the 
other  cases.  As  a  general  rule,  the  parts  heal  by  granula- 
tion in  the  course  of  four  or  five  weeks. 

Prostatitis  from  exposure  to  cold  and  dampness  is  not  an 
uncommon  occurrence  among  elderly  men  whose  urination 
may  or  may  not  have  been  impeded  before  such  exposure. 
From  the  cases  observed,  three  are  selected  to  illustrate  the 
ill  effects  of  a  phlegmasia  which  involves  the  mucous  mem- 
brane of  the  prostatic  region  and  of  the  urethro-vesical 
orifice,  together  with  a  very  superficial  layer  of  the  prostatic  ■ 


168 


parenchyma,  causing  an  oedematous  swelling  of  the  mucous 
membrane  that  may  be  likened  to  oedema  of  the  glottis 
from  the  suddenness  of  its  invasion  and  rapidity  of  swell- 
ing. In  two  or  three  hours  after  the  exposure  there  is  fre- 
quent and  difficult  urination,  and,  within  six  or  eight  hours, 
retention  of  urine. 

A  patient,  sixty-six  years  of  age,  who  had  never  had 
any  hindrance  to  urination,  left  the  city,  in  apparent  good 
health  to  spend  the  night  at  his  suburban  residence,  on  a 
cool  mid-September  evening.  From  the  railway  station  to 
his  house  the  distance  is  about  a  quarter  of  a  mile.  He 
walked  briskly  and  was  somewhat  heated  on  his  arrival. 
He  remained  for  a  time  out  of  doors,  and,  desiring  to  uri- 
nate, exposed  his  pudendal  region  in  the  act  of  relieving  his 
bladder.  At  that  moment  he  experienced  a  distinct  chilly 
sensation,  and  thought  nothing  of  it  until  later  in  the  night, 
when  he  was  several  times  obliged  to  urinate.  Before  sun- 
rise the  frequency  of  urination  had  greatly  increased,  so 
that  he  was  disturbed  every  ten  minutes,  suffering  much 
burning  pain  at  each  act.  He  returned  to  the  city  early  in 
the  morning,  when  he  was  unable  to  pass  a  single  drop  of 
urine.  The  catheter  was  used,  much  to  his  relief,  but  he 
could  not  afterward  urinate  spontaneously.  He  died  within 
six  months  from  the  date  of  the  attack.  The  necropsy  re- 
vealed a  hard,  thick,  bar-like  obstruction  at  the  urethro- 
vesical  orifice,  but  the  prostate  was  very  little  enlarged. 
This  urethro-vesical  bar  indicated  that  supramontanal  en- 
largement had  begun,  but  was  not  sufficient  to  interfere  with 
urination  until  the  advent  of  the  acute  phlegmasic  swelling. 


169 


It  is  evident  that  the  continuance  of  the  obstruction  was 
owing  to  an  abundant  unresolved  exudate. 

A  siinilar  accident  happened  to  a  patient,  fifty-eight 
years  of  age,  who  sat  for  several  hours  in  the  evening  on 
the  piazza  of  a  watering-place  hotel  late  in  the  autumn,  the 
air  being  chilled  and  the  fog  dense.  During  the  night  he 
was  unable  to  urinate,  and  from  that  time  was  compelled  to 
rely  upon  the  catheter  for  relief.  He  had  never  before  had 
any  impediment  to  urination. 

A  patient,  sixty-three  years  of  age,  who  in  the  course 
of  the  previous  ten  years  had  several  times  suffered  from 
retention  of  urine,  imprudently  sat  during  the  evening  on 
the  stone  steps  of  his  house  late  in  the  month  of  August. 
At  length,  feeling  chilly,  he  went  to  bed.  In  the  morning- 
he  was  unable  to  urinate,  and  from  that  moment  required 
frequent  catheterism  for  nearly  two  months,  after  which  he 
was  able  to  urinate  spontaneously,  but  could  not  completely 
empty  his  bladder,  the  urethro-vesical  obstruction  having 
become  permanent.  At  the  time  of  the  retention  of  urine 
the  prostate  was  considerably  swollen,  but  was  afterward 
reduced  to  nearly  its  normal  size,  except,  of  course,  in  the 
supramontanal  region. 

The  same  phlegmasia  occurs  very  commonly  in  young 
and  middle-aged  subjects  from  exposure  to  cold  and  damp- 
ness during  the  decline  of  acute  urethritis  or  during  a  de- 
bauch. This  has  been  improperly  called  acute  inflamma- 
tory stricture.  The  bladder,  suddenly  distending,  causes 
great  suffering,  and  the  patient  is  likely  to  apply  for  relief 
during  the  first  day.     Not  many  years  ago  these  cases  were 


170 


subjected  to  vigorous  antiphlogistic  treatment,  but  of  late 
years  tbe  first  .care  has  been  to  empty  the  bladder  by  the 
prompt  introduction  of  a  gum  catheter.  This  is  followed 
by  the  use  of  ice  suppositories  for  a  few  hours,  and  then  by 
free  catharsis.  Sometimes  a  single  catheterism  suffices,  but 
it  is  ordinarily  advisable  to  enjoin  two  or  three  days  of  re- 
cumbency and  the  free  use  of  diluent  beverages.  Deliques- 
cence, or  at  least  very  rapid  resolution,  generally  occurs  in 
these  last-named  cases. 

The  chronic  type  of  prostatitis — variously  named 
catarrhal  j^rostatitis,  mucous  prostatitis,  follicular  prosta- 
titis, canalicular  prostatitis,  prostatorrhoea,  etc. — is  of  much 
more  common  occurrence  than  the  acute  types,  and  be- 
gins in  the  mucous  membrane  of  the  prostatic  sinus, 
reaching  finally  the  utriculus,  the  prostatic  ducts,  crypts, 
and  interstitial  tissues.  Its  development  is  so  gradual 
that  often  it  is  not  recognized  for  a  long  time.  It  is 
ordinarily  one  of  the  phases  of  chronic  urethritis,  whether 
this  urethritis  be  the  outcome  of  acute  urethritis,  of  mas- 
turbation, or  of  venereal  excesses,  or  whether  it  is  excited 
by  hyperlithuria,  by  the  lodgment  of  urinary  calculi  in  the 
prostatic  sinus,  by  chronic  cystitis,  by  a  urethral  stricture, 
by  frequent  catheterism,  by  the  extension  of  phlegmasia 
from  the  seminal  vesicles,  by  the  irritation  caused  by 
hgemorrhoids,  or  by  the  prolonged  retention  of  catheters  in 
the  bladder.  Chronic  prostatitis  may  also  be  a  sequel  of 
acute  prostatitis.  Although  chronic  prostatitis  ordinarily 
afEects  young  and   middle-aged    men,  it  not  infrequently 


in 


occurs  among  elderly  men  suffering  from  prostatic  enlarge- 
ment. In  these  cases  it  is  the  outcome  of  the  frequent 
catheterism  rendered  necessary  by  the  urethro-vesical  ob- 
struction. 

The  chief  symptoms  of  chronic  prostatitis  are  sensations 
of  fullness  and  weight  in  the  perinseum  and  rectum,  perineal 
tenderness  experienced  in  the  sitting  posture,  dull  pains  in 
the  perineal  and  anal  regions  increased  by  active  exercise 
and  sexual  contact,  pains  in  the  lumbo-sacral  region  and  in 
the  lower  extremities,  occasional  painful  seminal  emissions, 
costiveness,  frequent  urination,  painful  urination  particu- 
larly at  the  close  of  the  act,  a  slight  muco-purulent,  yellow- 
ish urethral  discharge,  and,  during  defecation,  a  free  urethral 
discharge  of  milky  prostatic  fluid  rendered  slightly  viscous 
by  the  admixture  of  the  secretion  of  the  urethral  mucous 
glands.  The  characteristic  odor  of  the  mucus  of  these 
glands  is  imparted  to  the  prostatic  fluid  and  semen,  which,  by 
themselves,  are  odorless.  To  this  last  symptom  the  name 
prostatorrhoea  owes  its  origin,  and  from  this  symptom  arose 
the  erroneous  popular  belief  that  the  glairy  fluid  in  question 
was  semen.  To  some  patients  this  discharge  of  prostatic 
fluid  is  a  source  of  much  anxiety.  They  imagine  them- 
selves affected  with  seminal  incontinence  and  even  impo- 
tency,  and  become  the  easy  victims  of  designing  charlatans. 
In  certain  cases  the  sexual  act  is  attended  with  so  much 
pain  that  it  is  at  last  abandoned  and  in  time  the  desire  is 
abolished.  Such  patients  become  sullen  and  lead  a  life  of 
seclusion,  their  thoughts  are  centered  upon  their  supposed 
infirmity,  and  their  forebodings  are  of  countless  imaginary 


172 

evils.  This  mental  state  is  more  likely  to  exist  in  men 
whose  health  is  already  impaired,  but  undoubtedly  causes 
its  further  deterioration.  Their  sedentary  life  leads  to  loss 
of  appetite,  disturbance  of  digestion  and  consequent  hyper- 
lithuria,  costiveness,  leucomainal  toxaemia,  languid  circula 
tion,  etc. 

The  physical  characters  of  chronic  prostatitis  become 
known  partly  during-  life  and  partly  after  death.  Begin- 
ning in  the  mucous  membrane  of  the  prostatic  sinus,  it 
gradually  invades  the  ducts,  the  crypts,  and  the  interstitial 
tissues.  In  some  cases  the  prostate  is  soft,  in  other  cases 
it  is  indurated.  Either  condition  may  be  ascertained  dur- 
ing life  by  digital  rectal  exploration. 

In  a  large  proportion  of  cases  of  chronic  prostatitis  the 
mucous  membrane  of  the  prostatic  sinus  is  in  a  granular 
state,  which  can  be  seen  with  the  aid  of  the  urethroscope. 
In  some  cases  small  retention  cysts  from  the  occlusion  of 
ducts,  or  degeneration  cysts  from  isolated  gradual  degen- 
erative processes,  or  abscesses  from  sudden  local  necrosis, 
are  slowly  developed  in  the  substance  of  the  prostate  and 
are  detected  by  rectal  exploration  with  the  finger,  and  by 
subsequent  puncture  with  a  small  trocar.  Very  rarely  it  is 
found  that  the  greater  part  of  one  lobe  is  destroyed  by  an 
abscess. 

Dissection  of  the  prostates  of  patients  affected  with 
chronic  prostatitis,  dying  from  some  intercurrent  disease, 
has  revealed  the  granular  condition  to  which  reference  has 
already  been  made,  the  granular  mucous  membrane  being 
red  from    congestion    up  to   the  vesico-urethral   orifice,  a 


173 


spongy,  soft  state  of  the  prostate,  which  is  somewhat  larger 
than  natural  and  may  contain  degeneration  cysts  or  small 
abscesses,  or  a  hard  state  of  the  prostate,  which  is  decreased 
in  size  and  sometimes  contains  retention  cysts,  and  the 
utriculus  occasionally  filled  with  pus. 

When  the  prostatic  crypts  have  become  involved  in  the 
phlegmasic  process,  their  microscopic  sympexia  are  set  free 
by  the  exudate  and  are  then  metamorphosed  into  calculi 
which,  by  the  accretion  of  concentric  phosphatic  layers, 
attain  in  time  very  considerable  dimensions.  In  one  case 
a  thousand  such  calculi,  each  about  half  a  millimetre  in 
mean  diameter — except  three,  one  of  which  weighed  three 
grammes  fifty  centigrammes,  and  the  other  two  weighed 
together  twenty  centigrammes — were  removed,  through  a 
perineal  incision,  from  the  prostate  of  a  man  twenty-six 
years  of  age.  In  another  case  eighteen  prostatic  calculi 
were  similarly  removed  from  a  man  fifty-four  years  of  age. 
These  eighteen  calculi  averaged  seven  millimetres,  the 
largest  measured  ten  by  fourteen  millimetres,  the  smallest 
three  millimetres  ;  the  whole  weighed  one  hundred  and  forty 
grains — about  nine  grammes.  Both  patients  were  cured  by 
the  operation. 

In  perhaps  five  per  cent,  of  the  prostates  dissected  dur- 
ing the  past  twenty  years,  several  small  calcareous  concretions 
have  been  found  occluding  the  mouths  of  prostatic  ducts  or 
lying  free  in  the  prostatic  sinus,  and  in  a  much  greater 
percentage  of  these  prostates,  particularly  those  of  elderly 
men,  the  calcareous  transformation  was  verified  by  the  in- 
ordinately gritty  state  of  the  substance  of  the  organ.     This 


174 


it  seems  is  evidence  of  chronic  phlegmasic  action  sufficient 
to  disturb  or  even  to  kill  tlie  sympexia,  wMcli  then  become 
foreign  bodies.  It  is  when  these  foreign  bodies  are  not 
speedily  cast  away  that  they  receive  successive  layers  of 
calcium  phosphate  until  they  greatly  dilate  and  finally  de- 
stroy most  of  the  prostatic  crypts. 

In  chronic  prostatitis  arising  from  narrow  urethral  strict- 
ures, not  only  are  the  ducts  dilated  by  the  refluent  urine, 
but  the  prostatic  sinus  also  undergoes  expansion.  One  of 
the  specimens  exhibited  is  from  an  extreme  case  of  ectasia, 
the  prostatic  sinus  being  dilated  to  the  extent  of  containing 
at  least  thirty  grammes  (one  ounce)  of  fluid,  the  substance 
of  the  prostate  being  soft  and  spongy. 

The  diagnosis  of  chronic  prostatitis  is  based  upon  close 
analysis  of  the  symptoms,  examination  of  the  urine,  physi- 
cal exploration,  the  anatomical  characters,  and  the  history 
of  the  affection.  The  symptoms  can  be  rightly  interpreted 
only  in  connection  with  the  examination  of  the  urine  and 
the  physical  exploration. 

The  urine  of  patients  affected  with  chronic  prostatitis 
is  generally  somewhat  cloudy,  owing  to  the  presence  of  pus 
and  epithelium  from  the  prostatic  region  and  sometimes 
also  from  the  bladder.  The  many  shreds  and  scrolls  so 
commonly  seen  in  this  urine  are  shown  on  microscopical 
examination  to  consist  of  pus,  epithelial  cells,  and  some 
blood-cells  held  together  by  mucus.  x\mong  these  shreds 
and  scrolls  are  sometimes  seen  long  cylindrical  bodies  which 
appear  to  be  casts  of  the  smaller  prostatic  ducts.  Great 
quantities  of  octaedra  of  calcium  oxalate  are  frequently 


175 


found  in  the  urine  of  these  patients ;  at  times  lozenges  of 
uric  acid,  at  other  times  the  urates  in  great  abundance. 
Microscopic  sympexia  cast  away  from  the  prostatic  crypts 
are  often  found  in  this  urine,  particularly  in  the  case  of 
elderly  men. 

A  convenient  method  of  obtaining  pus  from  the  pros- 
tatic sinus  for  microscopical  examination  is  to  introduce 
into  the  sinus  of  the  urethral  bulb  a  hollow,  soft,  No.  12 
English  bougie,  with  an  acorn-shaped  vesical  extremity, 
with  three  or  four  perforations  at  the  base  of  the  acorn, 
and  to  syringe  in  four  or  five  ounces  of  warm  water  for  the 
purpose  of  washing  away,  by  the  retrograde  current,  the 
pus  that  may  have  accumulated  in  the  spongy  urethra. 
This  accomplished,  the  bougie  is  carried  onward  as  far  as 
the  urethro-vesical  region  and  then  withdrawn.  The  pus 
found  coating  the  base  of  the  acorn  is  then  placed  upon  a 
glass  slide,  properly  covered,  and  subjected  to  microscopic 
inspection.  Mixed  with  this  pus  are  many  epithelial  cells, 
perhaps  some  casts  of  the  smaller  prostatic  ducts,  and  pos- 
sibly a  few  sympexia,  but  no  spermatozooids. 

The  first  step  in  physical  exploration  is  digital  rectal 
examination.  By  this  it  is  ascertained  if  the  prostate  be 
tender  or  insensible  to  the  touch,  hard  or  soft,  decreased  or 
increased  in  size,  smooth  or  nodular ;  if  nodular,  whether 
the  nodules  be  firm  from  organized  plasma,  doughy  from 
purulent  accumulation,  tense  from  cystic  formation,  or  of 
stony  hardness  from  the  presence  of  calculi. 

The  next  step  in  this  exploration  is  an  examination  of 
the  urethra  for  the  purpose  of  excluding  urethral  stricture. 


176 

trachelocystitis,  or  vesical  stone.  Chronic  prostatitis  be- 
ing sometimes  the  indirect  outcome  of  urethral  stricture, 
the  urethra  should  be  explored  with  a  bulbous  bougie  to 
make  sure  of  the  existence  or  of  the  non-existence  of 
stricture.  The  granular  condition  already  referred  to  can 
be  ascertained  with  the  aid  of  the  urethroscope. 

The  sharp  pain  at  the  urethro-vesical  orifice  during 
urination  or  at  the  moment  of  entrance  into  the  bladder  of 
a  bougie  or  catheter  indicates  the  complication  trachelo- 
cystitis, which  is  so  frequent  that  the  coexistence  of  these 
afEections  has  given  rise  to  the  term  chronic  prostato-cys- 
titis.  The  persistent  vesical  pains  simulate  so  much  some 
of  the  symptoms  of  stone  as  to  warrant  an  exploration  of 
the  bladder  with  a  rectangular  staff  to  clear  any  doubt  in 
this  respect.  When  the  pain  caused  by  the  exploration  is 
slight  and  confined  to  the  prostatic  region,  the  case  may  be 
regarded  as  uncomplicated  chronic  prostatitis. 

The  treatment  of  chronic  prostatitis  is  varied  in  accord- 
ance with  its  different  phases,  complications,  and  conse- 
quences. 

Uncomplicated  chronic  prostatitis  attended  with  a  flow 
of  from  a  few  drops  to  nearly  a  drachm  of  prostatic  fluid 
during  defecation,  so  common  among  continent  men,  and 
still  more  so  among  those  addicted  to  masturbation,  re- 
quires moral  as  well  as  local  and  constitutional  treatment. 

The  moral  treatment  is  the  most  difiicult  of  the  self- 
imposed  tasks  of  the  physician,  who  must  employ  much 
circumspection  before  he  can  pass  judgment  upon  the 
needs  of  particular  cases.     In  examining  and  advising  any 


177 


individual,  lie  may  exercise  the  greatest  firmness,  tempered, 
however,  with  patience,  forbearance,  and  kindness.  Thus 
he  enlists  the  confidence  of  the  sufferer,  endeavoring  to 
lead  him  to  understand,  first,  that  his  local  ailment  is  cura- 
ble ;  second,  that  he  is  not  suffering  from  seminal  inconti- 
nence ;  third,  that  he  is  not  impotent ;  and  fourth,  that  he 
can  not  be  cured  unless  he  gives  up  the  bad  habits  he  may 
have  acquired,  and  occupies  his  mind  with  subjects  other 
than  his  ailments.  When  the  patient  is  responsive  to  the 
moral  treatment,  more  than  half  of  the  cure  may  be  con- 
sidered accomplished. 

The  local  treatment  of  uncomplicated  chronic  prostatitis 
consists  in  irrigating  the  prostatic  sinus  once  daily,  with  the 
object  of  washing  away  the  mucus  and  pus  which  may  have 
accumulated  in  the  sinus  and  in  the  larger  prostatic  ducts. 
The  fluid  for  irrigation  should  at  first  be  a  one-per-cent. 
watery  solution  of  boric  acid,  using  not  less  than  four 
ounces  of  this  solution  for  each  irrigation.  This  often  suf- 
fices in  certain  cases,  but  may  be  used  with  advantage  as  a 
preparatory  step  to  more  active  measures  when  such  are 
necessary.  The  manner  of  making  this  irrigation  is  to  in- 
troduce a  No.  8  or  No.  9,  English,  uniocular,  curved  gum 
catheter  into  the  membranous  region  of  the  urethra,  and  to 
slowly  inject  the  fluid,  which,  passing  through  the  prostatic 
urethra,  dislodges  and  carries  into  the  bladder  the  muco- 
purulent contents  of  the  prostatic  sinus.  If  any  of  the  fluid 
flows  out  of  the  urethra  beside  the  catheter,  it  is  an  index 
that  the  catheter  has  not  reached  the  membranous  region. 

In  that  case  the  instrument  should  be  made  to  advance  a 
12 


178 

little  farther ;  then  the  injection  surely  enters  the  prostatic 
region  and  bladder.  When  the  four  ounces  have  been 
thrown  in,  the  catheter  is  pushed  into  the  bladder,  whose 
contents  are  allowed  to  escape  into  a  glass  vessel  to  be  ex- 
amined for  flocculi  of  muco-pus  and  epithelium,  and  to 
make  sure  that  the  cleansing  process  has  been  successful. 

These  irrigations  are  very  effective  also  in  the  chronic 
prostatitis  of  elderly  men.  In  many  cases  the  prostatic 
sinus  is  filled  by  a  plug  of  tenacious  slime,  which  for  hours 
is  a  source  of  irritation  and  of  frequent  prostatic  spasms, 
until  it  is  suddenly  forced  out  by  a  stream  of  urine.  The 
daily  use  of  irrigations  with  the  boric-acid  solution  almost 
invariablv  has  the  effect  of  breaking  up  this  tenacious  slime, 
or  of  preventing  its  accumulation.  In  case  of  granular  ure 
thritis  of  the  spongy  portion,  it  is  wise  to  irrigate  the  whole 
canal.  When  these  simple  irrigations  are  insufficient  to 
relieve  the  local  distress,  the  use  of  steel  sounds  of  increas- 
ing size  has  the  double  effect  of  dilating  the  canal  and,  by 
compression,  of  causing  the  granulations  to  disappear.  The 
sound  should  not  be  passed  oftener  than  twice  each  week. 
In  conjunction  with  this  process  of  dilatation,  every  third 
or  fourth  day  the  prostatic  region  of  the  urethra  should  be 
irrigated  with  a  solution  of  nitrate  of  silver,  one  grain  to 
the  ounce,  increasing  its  strength  at  subsequent  sittings  to 
two,  three,  and  even  five  grains  to  the  ounce  of  distilled 
water,  and  using  only  one  ounce  of  the  sohition.  The  blad- 
der should  contain  a  few  ounces  of  urine,  so  that  the  nitrate 
of  silver  may  be  decomposed  and  rendered  harmless  to  its 
mucous  membrane.     The  method  of  G-uyon,  by  the  instiUa- 


179 


tion  of  five,  ten,  or  twenty  minims  of  nitrate-of-silver  solu- 
tion, from  five  to  thirty  grains  to  the  ounce,  is  also  era- 
ployed  in  chronic  prostatitis,  but  the  use  of  a  larger  quan- 
tity of  a  weaker  solution,  such  as  one  ounce,  is  preferable, 
as  the  fluid  has  a  better  chance  of  entering  the  prostatic 
duets,  and  it  is  not  desirable  that  the  strength  of  the  solu- 
tion exceed  fiv^  grains  to  the  ounce.  Before  making  the 
injection  the  prostatic  urethra  should  be  well  cleansed  with 
pure  water.  The  immediate  effects  of  the  injection  are  a 
severe  burning  pain  in  the  prostatic  region  and  frequent 
and  almost  irrepressible  urination,  lasting  an  hour  or  two 
hours.  There  may  even  be  a  slight  haemorrhage,  which, 
however,  soon  ceases.  Afterward  the  muco-purulent  dis- 
charge is  much  increased,  but  lessens  and  nearly  disappears 
in  two  or  three  days.  It  sometimes  happens  that  after  the 
first  or  second  injection  of  nitrate-of-silver  solution  there 
are  no  longer  any  manifestations  of  chronic  prostatitis,  but, 
as  a  general  rule,  several  injections  are  necessary  to  effect 
a  cure. 

Other  substances  have  been  used  in  solution  for  irriga- 
tion in  chronic  prostatitis,  such  as  mercuric  or  zinc  chlo- 
ride, copper  or  zinc  sulphate  (five  grains  to  the  ounce),  res- 
orcin,  otherwise  known  as  metadioxybenzol  (ten  grains  to 
the  ounce),  but  they  are  not  equal  to  nitrate  of  silver  in 
solution  of  moderate  strength,  the  great  advantage  of  ni- 
trate of  silver  being  that  it  is  decomposed  and  becomes  in- 
nocuous as  soon  as  it  has  caused  coagulation  of  the  albumin 
of  the  superficial  layer  of  epithelial  cells. 

In  some  cases  of  chronic  prostatitis,  owing  perhaps  to 


180 

a  slight  imprudence  or  error  in  diet,  the  urethral  discharge 
greatly  increases,  becomes  creamy,  simulating  acute  viru- 
lent urethritis.  There  are  inordinate  frequency  and  pain  in 
urination,  and  a  train  of  symptoms  which  are  very  apt  to 
mislead  the  inexperienced.  Such  patients  should  not  at 
first  be  subjected  to  local  treatment,  as  it  would  be  likely  to 
aggravate  the  phlegmasia  and  cause  some  serious  complica- 
tion. Three  or  four  days  of  rest  and  the  free  use  of  dilu- 
ent drinks  generally  suffice  to  cause  the  cessation  of  all 
these  phenomena.  Then  the  local  treatment  may  with  safety 
be  applied. 

It  is  scarcely  necessary  to  say  that  no  success  in  treat- 
ment can  be  attained  in  complicated  cases  unless  the  .  com- 
plication is  treated  at  the  same  time.  If  chronic  cystitis 
exists,  it  demands  special  local  treatment ;  if  a  urethral 
stricture  should  be  detected,  dilatation,  divulsion,  or  ure- 
throtomy might  be  required.  If  painful  haemorrhoids  or 
anal  fissures  are  the  complication  and  perhaps  also  the  cause, 
they  should  be  appropriately  treated.  When  prostatic  cal- 
culi have  already  formed,  they  should,  if  possible,  be  re- 
moved without  delay. 

In  those  cases  attended  with  constant  dull  pain  in  the 
perineal  region  and  tenderness  of  the  prostate  it  is  proper 
to  use  counter-irritants  for  five  or  six  weeks.  Painting  the 
perinseum  with  strong  tincture  of  iodine,  first  on  one  side 
of  the  rhaphe,  then  on  the  opposite  side,  every  two  or  three 
davs,  often  answers  the  purpose ;  otherwise  vesicating  col- 
lodion may  be  similarly  applied,  avoiding  the  scrotum  and 
anus,  and  covering  the  vesicated  part  with  a  thick  layer  of 


181 


absorbent  cotton.  Suppositories  of  opium  and  belladonna 
may  be  occasionally  used  to  relieve  pain. 

Small  cysts  or  abscesses  of  the  prostate  may  be  tapped, 
by  way  of  tbe  rectum,  with  a  small  trocar  and  irrigated  with 
peroxide-of-hydrogen  solution. 

Constitutional  medication  is  necessitated  by  the  generally 
impaired  health  of  most  sufferers  from  chronic  prostatitis, 
and  this  medication  is  subject  to  such  variations  as  may  be 
indicated  by  the  characters  of  the  constitutional  manifesta- 
tions. The  use  of  bitter  tonics  in  conjunction  with  an  im- 
proved diet  is  likely  to  sharpen  the  appetite  and  facilitate 
digestion.  Active  treatment  for  hyperlithuria  may  be  neces- 
sary. Iron  and  quinine  are  of  value  as  reconstituents.  Lax- 
atives soon  have  the  effect  of  preventing  faecal  accumulation, 
and  afterward  equal  parts  of  tincture  of  chloride  of  iron, 
tincture  of  cantharides,  and  fluid  extract  of  ergot,  given  in 
doses  of  ten  minims  twice  daily,  complete  the  internal  medi- 
cation. Then  frequent  general  bathing  followed  by  fric- 
tions, and  increasing  exercise,  comprise  the  hygienic  meas- 
ures. 

BuLBO-uRETHRAL  Adenitis. — Before  examining  the 
phlegmasic  processes  to  which  the  bulbo-urethral  glands 
are  subject,  some  points  in  their  history,  special  anatomy, 
and  physiology  may  with  profit  be  studied.  These  glands, 
the  analogues  of  the  vulvo-vaginal  glands,  were  discovered 
by  Mery,  and  a  very  brief  description  of  them  was  inserted 
in  the  Journal  des  savants,  June,  1684.  Fifteen  years  after 
this,  in  1699,  Cowper  published,  in  the  Philosophical  Trans- 


182 


actions,  a  note  on  these  glands,  and  in  1702  gave  of  them  a 
detailed  description,  and  they  have  since  borne  his  name. 
Several  other  anatomists  laid  claim  to  their  discovery  and 
each  gave  them  a  new  name,  such  as  little  prostates,  acces- 
sory prostates,  inferior  prostates,  antiprostates,  etc.  In 
1849  Gubler  published,  as  his  inaugural  thesis,  an  exhaustive 
study  of  the  anatomy  and  the  phlegmasise  of  these  glands, 
and  adopted  for  them  the  name  of  bulbo-urethral  glands  on 
account  of  their  site.  They  consist  of  a  pair  of  compound 
racemose  glands  encapsulated  by  fibrous  tissue,  situated  be- 
hind the  urethral  bulb,  between  the  two  layers  of  the  tri- 
angular ligament,  in  the  substance  of  the  ischio-urethral 
muscle,  and  beneath  the  membranous  portion  of  the  urethra. 
They  are  generally  about  one  millimetre  on  each  side  of  the 
median  line,  but  sometimes  in  contact.  They  are  globular, 
discoid,  or  ovoid  in  form,  and  from  five  to  eight  millimetres 
in  mean  diameter.  In  the  foetus  they  are  proportionately 
much  larger  than  in  the  adult.  In  some  of  the  lower  ani- 
mals, as  the  Rodentia,  they  are  very  large.  In  color  they 
are  pinkish  yellow,  in  consistence  firm  and  elastic. 

In  structure  they  are  similar  to  the  racemose  glands  and 
consist  of  roundish  cellules,  ranging  from  the  one  six-hun- 
dredth to  the  one  three-hundredth  of  an  inch  in  diameter, 
grouped  around  small  ducts  after  the  manner  of  bunches  of 
grapes,  the  whole  being  bound  by  connective  tissue  and 
capillary  blood-vessels.  The  cellules  and  ducts  are  lined  by 
a  cubical  epithelium.  The  ducts  of  several  primary  lobules 
unite  and  form  larger  ducts  which  end  in  a  common  excre- 
tory duct. 


183 


Each  gland  has  a  single  common  excretory  duct  which 
emerges  from  the  anterior  extremity  of  the  gland.  This 
excretory  duct  varies  in  length  from  three  to  six  centime- 
tres, and  in  diameter  from  a  quarter  of  a  millimetre  to  one 
millimetre.  As  it  emerges  from  the  gland,  this  duct  enters 
the  substance  of  the  urethral  bulb  and  traverses  it  obliquely 
from  behind  forward  for  the  space  of  one  centimetre,  where 
are  found  the  accessory  lobules  which  led  Cowper  to  be- 
lieve in  the  existence  of  a  third  gland.  The  duct  then  takes 
a  nearly  longitudinal  course  underneath  the  urethral  mu- 
cous membrane  for  a  distance  varying  from  two  to  five  cen- 
timetres and  ends  in  a  very  narrow  orifice  beside  the  median 
line  a  little  in  advance  of  its  fellow,  the  two  very  rarely 
having  a  common  orifice.  This  orifice  is  sometimes  so  small 
as  scarcely  to  admit  a  hair.  It  is  generally  very  difficult  and 
often  impossible  to  find  this  orifice  even  in  carefully  dissected 
fresh  specimens.  The  mucous  membrane  of  the  ducts  is 
surmounted  by  a  cubical  epithelium  resting  upon  a  thin 
membrane  surrounded  by  longitudinal  and  circular  bands  of 
smooth  muscle  tissue  to  be  found  also  among  the  divisions 
of  the  duct  in  the  substance  of  the  gland. 

The  secretion  of  the  gland  in  the  natural  state  is  color- 
less and  viscid,  and  in  pathic  states  becomes  opaline  or  even 
markedly  turbid,  without,  however,  losing  its  viscidity. 
This  secretion,  whether  in  health  or  in  disease,  is  much 
more  consistent  than  that  of  any  of  the  uro-genital  glands, 
and  it  is  this  consistence  which  distinguishes  it  so  well  from 
the  others.  This  viscidity  of  the  mucoid  fluid  is  such  that 
it  is  easy  to  draw  it  into  threads  from  ten  to  fifteen  centi- 


184 

metres  in   length.      It  is   of  alkaline  reaction,   and  when 
rubbed  has  the  property  of  frothing  like  soap-suds. 

These  glands  are  annexes  of  the  genital  as  well  as  of  the 
urinary  apparatus.  As  genital  organs,  their  secretion,  pro- 
fuse at  the  beginning  of  the  act,  serves  to  lubricate  the 
glans  penis  to  facilitate  intromission,  and,  continuing  during 
the  act,  serves  to  dilute  the  semen.  As  urinary  organs,  their 
secretion  is  among  those  designed  to  lubricate,  and  so  pro- 
tect the  urethral  mucous  membrane. 

Bulbo-urethral  adenitis — phlegmasia  of  a  bulbo-urethral 
gland — is  ordinarily  the  outcome  of  urethritis,  but  may  also 
arise  in  consequence  of  a  blow  upon  the  perinaeum  or  of  an 
injury  of  the  gland's  duct  by  the  accidental  penetration  of 
a  capillary  bougie.  The  left  seems  to  be  more  commonly 
attacked  than  the  right,  and  very  exceptionally  are  both 
glands  affected.  The  phlegmasia  may  be  acute  or  chronic. 
In  the  great  majority  of  cases  the  acute  type  resolves  in  a 
short  time,  suppuration  being  a  rare  termination.  The 
chronic  type  is  more  frequent  than  it  is  generally  supposed 
to  be,  and  often  constitutes  one  of  the  varieties  of  chronic 
urethral  discharge.  Observation  of  this  chronic  dis- 
charge, with  induration  and  enlargement  of  the  glands 
led  Cowper  and  several  of  his  contemporaries  to  believe' 
that  "  gonorrhoea "  was  often  caused  by  phlegmasia  of 
the  bulbo-urethral  glands,  whereas  this  phlegmasia  is 
in  reality  one  of  the  occasional  consequences  of  "gonor- 
rhoea," 

Acute  bulbo-urethral  adenitis  consequent  upon  acute 
urethritis  is  often  overlooked,  because  the  perineal  pain  and 


185 


tension  wMdi  so  frequently  occur  on  the  second,  third,  or 
fourth  week  of  urethritis  are  not  rightly  interpreted,  or  not 
considered  worthy  of  attention,  or  perhaps  they  are  at- 
tributed to  a  purely  neurotic  condition,  and  the  cessation  of 
the  pain  is  believed  to  be  due  to  the  remedies  that  may 
have  been  administered,  whereas,  in  the  majority  of  cases, 
the  pain  ceases  owing  to  rapid  resolution  of  the  phleg- 
masia. 

The  subjective  symptoms  of  this  mild  type  of  bulbo- 
urethral adenitis  are  painful  tension  in  the  perineal  region 
on  the  affected  side,  tenderness  to  pressure  while  the  patient 
is  in  the  sitting  posture,  pain  during  walking  exercise,  from 
friction  by  the  clothing,  and  more  or  less  burning  sensation 
in  the  region  of  the  urethral  bulb. 

The  objective  symptoms  are  slight  tumefaction  corre- 
sponding to  the  situation  of  the  gland,  which,  though  hard 
and  increased  in  volume,  is  movable  ;  moderate  compression 
of  the  gland  with  the  linger,  causing  more  or  less  pain, 
which  is  propagated  to  the  urethra.  There  is  no  febrile  re- 
action, no  redness  of  the  skin. 

The  progress  of  acute  bulbo-urethral  adenitis  is  ordi- 
narily very  rapid.  As  a  general  rule,  resolution  begins  in  a 
few  days.  Otherwise,  suppuration  is  established  in  the 
course  of  ten  days  or,  at  most,  two  weeks.  The  phlegmasia, 
at  first  confined  to  the  gland,  finally  extends  beyond  its 
fibrous  capsule  and  into  the  ambient  connective  tissue,  and 
there  is  peri-adenitis.  Then  the  gland  can  no  longer  be 
felt,  for  it  lies  in  a  pus  cavity.  The  abscess  sometimes  en- 
croaches upon  the  opposite  side,  and  extends  forward  to  the 


186 


scrotum.  The  skin  is  oedematous,  becomes  red,  then  livid 
in  the  center  of  the  swelling,  and  at  length  ulcerates  and 
gives  issue  to  the  pent-up  pus,  and  later,  perhaps,  to  urine, 
unless  timely  surgical  aid  had  been  obtained.  The  begin- 
ning of  the  suppurative  process  is  known  by  febrile  reaction, 
throbbing  perineal  pains,  and  increase  of  tenderness  and 
tension. 

Among  the  consequences  of  neglected  bulb o- urethral 
adenitis  are  retention  of  urine  from  mechanical  compres- 
sion of  the  urethra  by  the  abscess,  perforation  of  the  ure- 
thra and  urinary  fistula,  and  obliteration  of  the  excretory 
duct  of  the  gland. 

The  diagnosis  is  easy  during  the  period  of  increase  of 
the  phlegmasia.  The  situation  of  the  swelling,  its  mobility, 
its  tenderness,  viewed  in  conjunction  with  the  history  of 
the  case,  demonstrate  the  existence  of  bulbo-urethral  adeni- 
tis. But  when  peri-adenitis  is  superadded,  it  may  be  con- 
founded with  urinary  or  simple  abscess  or  a  boil.  Here, 
again,  the  history  of  the  symptoms  comes  in  aid  to  make 
certain  the  true  nature  of  the  swelling.  If,  after  the  ab- 
scess has  been  opened,  a  fistula  persist  for  months  and  dis- 
charge a  very  -sascid  fluid,  particularly  at  the  beginning 
of  sexual  contact,  it  may  be  asserted  with  confidence 
that  this  fistula  springs  from  the  gland  or  from  its  duct, 
which  may  be  obliterated  at  its  anterior  portion,  A 
fistula  giving  issue  also  to  urine  indicates  perforation  of 
the  urethra. 

The  treatment  of  acute  bulbo-urethral  adenitis  during  its 
period  of  increase   should   be  antiphlogistic,  consisting  in 


187 

the  application  of  half  a  dozen  leeches  to  the  perinaeum 
after  which  the  ice-bag  is  to  be  used  for  three  or  four  days. 
If  at  the  expiration  of  that  time  resolution  has  not  begun, 
the  swelling  and  tension  have  increased,  and  the  pain  is 
throbbing,  an  incision  should  forthwith  be  made  into  the 
substance  of  the  gland.  The  patient  is  placed  in  the 
lithotomy  posture,  a  narrow,  straight  bistoury  is  plunged 
into  the  swelling  at  its  most  prominent  point,  and  the 
wound  is  enlarged  to  half  or  three  quarters  of  an  inch  in 
withdrawing  the  instrument.  A  few  drops  only  of  pus  or 
none  may  flow,  but  the  tension  will  have  been  relieved  and 
perforation  of  the  urethra  prevented  by  this  timely  incision, 
without  which  it  is  almost  certain  to  occur.  As  soon  as 
the  incision  is  made  the  cavity  of  the  abscess  should  be 
irrigated  with  peroxide-of-hydrogen  solution  until  the  re- 
turned fluid  is  clear.  The  wound  is  then  dressed  antisepti- 
cally.  Under  favorable  circumstances  cicatrization  is  com- 
plete in  the  course  of  ten  days.  In  the  case  of  an  abscess 
containing  an  ounce  or  two  of  pus  there  is  very  likely  per- 
foration of  the  urethra,  and  the  healing  process  is  necessa- 
rily long.  To  insure  cicatrization,  the  patient  is  not  allowed 
to  urinate  except  through  a  catheter.  In  the  case  of  a 
persistent  fistula  springing  from  the  bulbo-urethral  gland 
or  its  duct,  attempts  have  been  made  to  stop  the  flow  of 
viscid  mucus  by  injecting  through  the  fistulous  orifice 
different  fluids  designed  to  impair  the  structure  of  the 
gland,  such  as  nitrate  of  silver,  tincture  of  iodine,  etc.,  but 
generally  without  success.  Excision  of  the  gland  was  pro- 
posed by  Grruget,  but  it  does  not  appear  that  he  has  ever 


188 


performed  this  operation,  which,  from  the  situation  and 
relations  of  the  gland,  would  present  no  great  difficulties, 
and  which  is  justifiable  in  view  of  the  facts  that  the  affected 
gland  is  of  no  further  use,  and  that  the  constant  discharge 
of  the  viscid  mucus  is  a  source  of  no  little  annoyance  to  the 
patient. 


189 


VIII. 

Urethritis  ;  its    Nature,   Causes,   and  Diagnosis. 

Urethritis,  the  most  common  of  all  the  affections  of 
the  uro-genital  apparatus,  is  a  phlegmasic  process,  beginning 
generally  in  the  mucous  membrane  of  the  urethra  and  ordi- 
narily characterized  by  pain,  ardor,  dysuresis,  and  a  more 
or  less  abundant  muco-purulent  discharge.  In  many  cases 
it  is  contagious,  but  in  the  great  majority  it  is  non-conta- 
gious. 

This  phlegmasia  was  named  urethritis,  in  the  year  1802, 
by  Bosquillon,  because  he  regarded  the  word  urethritis  as 
expressing  the  locality  and  the  phlegmasic  character  of  the 
disease,  and  "gonorrhoea  and  blennorrhagia  "  as  failing  to 
convey  the  idea  that  the  urethra  is  in  a  state  of  phlegmasia  ; 
the  one  meaning  a  flow  of  semen  and  the  other  a  breaking 
forth  of  mucus.  Therefore  it  was  that  he  followed  the  ex- 
ample of  Sauvages  in  the  use  of  the  suffix  itis  to  denote 
phlegmasia,  and  accordingly  constructed  the  word  urethritis 
to  express  a  correct  idea  of  the  nature  and  seat  of  the  affec- 
tion, ^.  e.,  a  phlegmasia  of  the  urethra. 

"  Gonorrhoea  "  is  the  most  ancient  of  the  designations  of 
this  disease,  and  was  used  because  of  the  supposition  that 
the  discharge  was  semen  and  originated  in  the  seminal  vesi- 
cles ;  and  this  erroneous  designation  is  still  used  almost 
universally,  although  it  is  more  than  three  centuries  since 
urethritis  was  distinguished  from  the  so-called  gonorrhoea. 


190 


In  the  sixteenth  century  Ambroise  Pare  spoke  of  gonor- 
rhoea as  an  involuntary  discharge  of  semen,  and  of  chaude- 
disse  (clap)  as  a  purulent  discharge  which  he  believed  to 
originate  in  the  seminal  vesicles  or,  at  least,  in  the  prostatic 
region  of  the  urethra.  William  Cockburn  was  the  first" 
English  author  to  assert  that  "  gonorrhoea "  was  seated  in 
the  urethral  mucous  membrane  and  not  in  the  prostate  or 
seminal  vesicles.  The  first  edition  of  his  work,  On  the 
Symptoms,  Nature,  Causes,  and  Cure  of  Oonorrhoea,  appeared 
in  London  in  the  year  I7l3,  and  the  fifth  edition  in  1*728. 
Many  physicians  who  are  acquainted  with  these  facts  still 
persist  in  speaking  of  the  flow  of  pus  in  urethritis,  in  vul- 
vitis, and  in  vaginitis,  as  "  gonorrhoea,"  which  means  nothing- 
more  than  a  running  of  semen,  because,  they  urge,  the  term 
has  been  sanctioned  by  long  usage.  Because  an  error  has 
been  reiterated  for  three  thousand  years  or  more  assuredly 
does  not  make  it  less  an  error,  and  the  long  existence  of 
this  evil  in  language  is  certainly  no  argument  in  favor  of 
sanctioning  its  continual  perpetration.  Otherwise,  how  great 
would  be  the  inconsistency  of  those  who  are  striving  to 
bring  the  science  of  medicine  to  its  proper  level  in  this 
nineteenth  century  of  progress  ! 

"  Blennorrhagia,''''  an  outbreak  of  mucus,  was  first  em- 
ployed by  the  Austrian,  Swediaur,  in  the  latter  part  of  the 
last  century,  in  preference  to  "  gonorrhoea,"  which,  as  he  says, 
implies  a  flow  of  semen,  while  in  reality  nothing  of  the  kind 
ever  occurs  in  this  disease.  But  the  word  "  blennorrhagia  " 
fails  to  indicate  that  the  urethra  is  in  a  diseased  condition. 
Even  if   the  adjective    urethral   were  always    prefixed  to 


191 


"  blennorrhagia,"  tlie  two  words  would  also  fail  to  convey 
the  idea  of  phlegmasia  of  the  urethra.  Although  many 
different  words  have  been  proposed  as  substitutes  for  these 
two  obviously  inaccurate  terms,  the  French  still  adhere  to 
"blennorrhagia,"  which  they  originally  borrowed  from  the 
eminent  Austrian  syphilographer. 

"  Venereal  catarrh  "  is  another  expression  now  commonly 
used,  in  Germany  and  other  countries,  instead  of  "  gonor- 
rhoea." It  was  suggested  in  1806  by  Capuron,  a  French- 
man. Venereal  catarrh  of  what  particular  part  or  mucous 
membrane  of  the  body  does  not  appear  in  the  expression. 
But  catarrh  means  simply  a  downward  flow,  not  even  a  flow 
of  mucus.  Therefore  catarrh  fails  to  designate  the  true 
character  of  urethritis. 

It  is  often  asked.  Is  not  "  gonorrhoea,  or  blennorrhagia, 
or  venereal  catarrh "  something  more  than  a  phlegmasic 
affection  ?  Sometimes  it  is,  and  in  that  case  there  is  ure- 
thral chancre,  chancroids,  or  mucous  patches — otherwise, 
"  gonorrhoea,  blennorrhagia,  and  venereal  catarrh "  have 
never  conveyed  to  the  mind  of  any  thoughtful  reader  and 
investigator  the  faintest  notion  of  phlegmasia,  and  to  such 
the  only  meaning  they  express  is  a  flow  of  semen  in  the 
first  case,  an  outbreak  of  mucus  in  the  second,  and  a  down- 
ward flow  from  venery  in  the  third  case.  It  is  asked  also 
with  equal  frequency.  Is  there  not  high  authority  for  say- 
ing that  the  terms  "  gonorrhoea,  blennorrhagia,  and  venereal 
catarrh  "  should  be  applied  to  that  form  of  disease  which 
is  contagious,  and  urethritis  to  that  which  is  non-conta- 
gious ?     Yes,   high    authorities  have  made    the  assertion 


192 

without  agreeing  wMcli  of  the  first  three  terms  should  be 
used ;  but  when  high  authorities  misuse  words  there  is  no 
obligation  to  follow  their  bad  example. 

Many  other  names  have  been  proposed  to  take  the  place 
of  "  gonorrhoea  "  ;  among  them,  arsura,  pyorrhoea,  and  syphi- 
loid. The  latter  was  used  for  a  time  by  Ricord.  None  of 
these  names  had  a  long  survival,  for  they  were  most  unfit. 
But  "  gonorrhoea,  blennorrhagia,  and  venereal  catarrh  "  are, 
so  far,  examples  of  the  survival  of  the  unfittest.  It  is  to 
be  hoped  that  urethritis,  answering  as  it  does  all  present 
needs  and  indicating  so  clearly  the  phlegmasic  character  of 
the  disease  in  the  male,  as  do  vulvitis  and  vaginitis  in  the 
female,  may  survive  all  those  unfit  names  that  always  give 
a  wrong  impression  if  they  convey  any  idea  whatever.  Ar- 
sura was  spoken  of  by  John  Ardern  (1320  to  1370)  as  an 
interior  heat  with  excoriation  of  the  urethra,  and  he  spoke 
of  this  same  arsura  as  occurring  in  the  genitalia  of  women. 
Arsura  was  also  used  as  synonymous  with  erysipelas.  The 
popular  saying,  "  He  was  burnt "  (meaning  that  he  contract- 
ed venereal  disease),  is  likely  to  have  originated  from  the  old 
word  arsura,  which  was  apparently  technical  in  the  four- 
teenth century  and  coined  from  ardere,  arsum,  to  burn, 
burnt. 

The  names  given  to  urethral  phlegmasia  by  the  vulgar 
of  several  nations  in  some  respects  are  more  appropriate 
than  those  employed  by  the  medical  profession.  These 
names,  based  upon  different  manifestations,  are  surely  not 
worse  than  "  gonorrhoea,  blennorrhagia,  or  venereal  catarrh." 
For  example,  the  common  people  of  England  and  of  this 


193 

country   call   urethritis    dap,  the   French   chaudepisse,   the 
German  Tripper,  and  the  Spanish  purgacion. 

Clap  is  derived  from  the  old  French  clapier,  which 
means  a  burrow,  a  hiding  place,  and  is  often  applied  by 
surgeons  to  burrowing  abscesses.  It  means  also  a  filthy 
place,  a  hovel,  or  brothel.  The  term  clap  may  have  been 
adopted  on  account  of  this  meaning  of  clapier — a  hovel  or 
brothel  where  dwelt  the  women  from  whom  the  disease  was 
supposed  to  be  contracted,  or  perhaps  on  account  of  the 
filthy  condition  of  the  genitalia  of  these  women. 

Chaudepisse  was  suggested  by  the  great  scalding  which 
is  experienced  in  urination  during  the  second  or  stage  of 
increase  of  urethritis.  For  the  milder  cases  the  people  use 
the  terms  echauffement,  heating,  and  coulante,  running. 

Tripper  is  taken  from  trip,  which  means  to  drop  or 
drip,  and  has  reference  to  the  dripping  of  the  pus  from  the 
urethra. 

Purgacion,  from  pur  gar  e,  purgatum,  to  cleanse,  has  ref- 
erence to  the  abundant  discharge,  which  the  vulgar  imagine 
"  cleanses  the  system  of  a  humor."  It  may  also  have  refer- 
ence to  the  fact  that  it  is  sometimes  contracted  from  women 
during  the  menstrual  period,  for  the  people  call  the  menses 
purgaciones,  which  they  take  literally  from  the  Latin. 

Antiquity  of  Urethritis.— There  does  not  appear  to  be 
any  historic  period  when  urethritis  was  unknown.  Du jar- 
din  and  Peyrihle,  in  the  history  of  surgery  from  its  origin 
to  their  day,  speak  of  the  great  frequency  of  "  gonorrhoea  " 
in  the  East,  and  in  alluding  to  the  operation  of  "  circumcis- 
ion," which  was  employed  partly  to  prevent  venereal  disease 
13  ' 


194 

trace  the  origin  of  this  operation  to  a  period  antecedent  to 
the  time  of  Abraham,  Moses  very  clearly  points  out  "gon- 
orrhoea "  as  existing  in  his  time,  and  his  sanitary  laws  tend- 
ing to  its  prevention  are  admirable,  and,  if  followed  to  the 
letter,  would  unquestionably  lead  very  materially  to  the  de- 
crease of  the  disease.  Hippocrates,  Galen,  and  Celsus  dis- 
course upon  this  disease  and  its  causes,  and  nearly  all  the 
medical  writers  of  the  middle  ages  make  reference  to  ure- 
thritis. 

Thk  nature  of  urethritis  was  long  in  dispute,  and  the 
question.  Is  it  an  infectious  disease,  a  simple  phlegmasic 
process,  or  a  contagious  affection  sui  generis  ?  was  earnestly 
discussed  by  able  physicians,  whose  conclusions  were  so  di- 
verse that,  for  convenience,  they  were  classed  and  designated 
as  the  identists  and  the  non-identists.  The  identists  were 
those  who  asserted  that  "  gonorrhoea  "  and  syphilis  are  iden- 
tical diseases,  i.  e.,  that  "  gonorrhoea "  and  chancres  are 
produced  by  one  and  the  same  virus,  and  that  "gonorrhoea  " 
can  produce  chancres  and  vice  versa.  The  early  authors  who 
treated  of  syphilis  were  not  identists — that  is  to  say,  they 
made  a  distinction  between  the  "  simple  chancre,"  the  in- 
fecting chancre,  and  urethritis,  and  it  was  not  until  about  the 
middle  of  the  sixteenth  century  that  the  distinctions  of  these 
three  diseases  ceased,  and  that  the  doctrine  of  identism  was 
promulgated  by  Musa  Brasavola,  of  Ferrare,  and  generally 
accented.  This  doctrine  continued  in  vogue  until  the  latter 
part  of  the  eighteenth  century,  and  was  first  questioned  by 
Balfour  (I'zeY),  then  by  Tode,  of  Copenhagen  (1777),  and 


195 


by  Fabre,  a  disciple  of  the  renowned  Petit,  who  showed  that 
he  had  doubts  upon  the  question  of  identism  when  he  as- 
serted that  the  consequences  of  "  gonorrhoea  "  were  not  the 
same  as  those  of  chancre.  The  first  edition  of  his  work  on 
venereal  diseases  was  published  in  1758.  Hernandez,  of 
Toulon,  a  surgeon  of  the  French  navy,  published,  in  1812, 
a  monograph  of  348  octavo  pages  to  establish  the  non-iden- 
tityof  the  "gonorrhoea!  and  syphilitic  viruses." 

The  answer  that  may  now  be  made  to  the  question  re- 
specting the  nature  of  urethritis  accords  with  neither  that 
of  the  identists  nor  that  of  the  non-identists,  which  are  so 
extreme,  but  includes  all  that  seems  rational  from  each  side, 
i.  e.,  urethritis  is,  in  all  cases,  a  phlegmasic  process.  It  is 
often  contagious,  but  most  frequently  it  is  simple,  non-con- 
tagious. It  is  contagious  but  non-infecting  when  it  arises 
from,  urethral  chancroids;  it  is  styled  virulent  when  it  arises 
from  the  contagium  of  virulent  vulvitis  or  vaginitis,  and  it 
is  infecting  when  due  to  urethral  chancres  or  mucous  patches. 
It  is  not  auto-inoculable  when  simple  or  when  due  to  an  in- 
fecting chancre.  It  is  auto-inoculable  when  owing  to  a  non- 
infecting  chancre,  called  chancroid  by  Clerc. 

John  Hunter  was  at  the  head  of  the  identists,  and  Ben- 
jamin Bell  ably  and  eloquently  pleaded  the  cause  of  the  non- 
identists.  Hunter  declared  that  "  gonorrhoeal "  virus  was 
capable  of  producing  chancre  and  chancrous  virus  of  pro- 
ducing "  gonorrhoea."  The  great  master  endeavored  to  set- 
tle this  question  in  the  month  of  May,  1767,  by  making  an 
inoculation  upon  the  prepuce  and  another  upon  the  glans 
penis  with  pus  taken  from  the  urethra  of  a  patient  whom 


196 


he  believed  to  be  affected  with  "  gonorrhoea."  There  re- 
sulted two  chancres  which  were  followed  by  constitutional 
syphilis.  He  therefore  concluded  that  the  two  diseases  pro- 
ceeded from  the  same  virus.  A  detailed  account  of  this 
event  with  its  ultimate  result  is  given  by  Hunter  in  his 
treatise  on  The  Venereal  Disease,  London,  1788,  pp.  324-327. 
It  now  seems  fair  to  assume  that  the  urethral  pus  used  in 
this  experiment  was  the  product  of  a  syphilitic  sore  of  the 
urethra. 

Benjamin  Bell  took  a  diametrically  opposite  view  of  the 
subject,  and,  to  overthrow  the  doctrine  espoused  by  Hunter, 
made  an  elaborate  and  strong  argument,  abundantly  illus- 
trated by  cases,  in  which  his  final  conclusion  was,  that  the 
pus  of  chancre  could  never  produce  "  gonorrhoea  "  and  that 
the  pus  of  "  gonorrhoea  "  could  never  produce  chancre.  This 
argument,  contained  in  the  first  chapter  of  Bell's  work  on 
Gonorrhoea  virulenta  and  lues  venerea,  1793,  entitled  the 
consideration  of  the  question  whether  "  gonorrhoea "  and 
lues  venerea  originate  from  the  same  contagion,  is  well  wor- 
thy of  careful  perusal  by  those  who  may  wish  to  investigate 
the  question. 

Both  eminent  observers  had  their  adherents,  who  warm- 
ly and  ably  argued  the  question  which,  many  years  after  the 
death  of  the  two  contestants,  continued  to  be  discussed.  It 
was  finally  settled  by  the  concurrent  labors  of  three  earnest 
workers  in  this  field  of  medicine — namely,  Ricord,  Basse- 
reau,  and  Cullerier — but  they  shall  now  speak  for  themselves 
through  the  last  named,  who  expresses  their  ideas  substan- 
tially as  follows  :  Ricord,  who  has  made  inoculations  of  vene- 


197 

real  matter  on  the  largest  scale,  has  come  to  the  conclusion 
that  simple  urethritis  is  never  inoculable,  that  is  to  say,  pro- 
duces no  specific  sore,  but  that  when  a  specific  sore  results 
from  inoculation  with  urethral  pus  it  is  because  there  exists 
in  the  urethra  a  chancre  which  had  escaped  detection.  But 
these  observations,  which  at  first  sight  seemed  to  throw  such 
great  light  upon  the  question,  have  lost  much  of  their  value 
since  the  publication  of  the  work  of  Bassereau,  before  which 
Ricord  believed  that  chancre  and  syphilis  were  the  same 
thing.  From  an  exhaustive  and  conscientious  clinical  study 
of  the  subject,  Bassereau  was  forced  to  conclude  that  all 
chancres  were  not  of  the  same  nature  ;  that  whenever  there 
were  syphilitic  symptoms,  these  had  been  preceded  by  an 
indurated  chancre  ;  that  the  indurated  chancre  has  always 
originated  from  another  indurated  chancre  ;  and  that  a  soft 
chancre  has  always  been  due  to  another  soft  chancre  and 
never  caused  syphilis.  Cullerier  at  first  combated  these 
ideas,  as  he  had,  though  rarely,  seen  constitutional  symp- 
toms follow  soft  chancres  ;  and  it  was  not  until  the  '  year 
1857  that  Ricord  accepted  the  doctrine  of  Bassereau.  In 
endeavoring  to  establish  the  differential  characters  of  the 
two  chancres,  Ricord  offered  the  following  proposition :  the 
soft  chancre  is  inoculable  for  an  indefinite  period,  while  the 
indurated  chancre  can  scarcely  ever  be  inoculated — on  the 
infected  individual  of  course.  This  is  a  direct  contradic- 
tion of  his  original  proposition,  which  was  to  the  effect  that 
what  distinguishes  virulent  urethritis,  urethral  chancre,  from 
simple  urethritis  is  that  the  former  is  inoculable,  and  that 
whenever  the  inoculation  is  negative  in  urethritis  there  is 


198 


no  syphilis.  On  the  other  hand,  Ricord  maintains  that  the 
indurated  chancre  alone  gives  syphilis  and  is  rarely,  if  ever, 
auto-inoculable,  and  that  the  soft  chancre  has  the  property 
of  being  inoculated  upon  the  suiferer.  Therefore,  says  Cul- 
lerier,  vs^henever  an  inoculation  is  made  with  the  pus  of  ure- 
thritis, if  this  inoculation  be  successful,  it  is  to  be  concluded 
that  there  exists  in  the  urethra  a  soft  chancre  and  that  there 
will  not  follow  any  constitutional  symptoms.  If  the  inocu- 
lation is  negative,  this  will  afford  no  proof  whatever  that 
there  will  not  follow  constitutional  symptoms,  inasmuch  as 
the  indurated  chancre  rapidly  loses  its  property  of  being  in- 
oculated. 

From  these  statements  of  the  case  it  is  plain  that  what 
has  been  said  of  the  value  of  inoculation  to  serve  in  distin- 
guishing the  two  species  of  urethritis  should  be  blotted  out, 
or  at  least  should  be  given  another  signification,  for  it  is 
evident  that  the  most  inoculable  is  the  least  dangerous.  The 
evidence  furnished  by  inoculation  is  therefore  not  to  be  ab- 
solutely depended  upon  in  the  distinguishing  of  simple, 
chancrous,  and  chancroidal  urethritis.  The  more  rational  and 
tenable  position  in  regard  to  the  nature  of  urethritis,  so  far 
as  it  is  related  to  chancre  and  chancroid — and  this  position 
is  based  upon  a  careful  analysis  of  the  propositions  of  both 
the  identists  and  non-identists  and  upon  clinical  observa- 
tion— is  that  urethritis  may  be  simple,  or  contagious,  or  it 
may  be  the  consequence  of  a  non-infecting,  or  of  an  infect- 
ing chancre,  either  of  which  being  accidentally  situated  in 
the  urethra,  and  acting,  so  far  as  the  urethra  is  concerned, 
as  a  local  irritant.     The  primary  lesion  of  syphilis  per  se 


199 

possesses  no  inherent  property  whicli,  other  than  as  a  local 
irritant,  may  cause  urethritis,  the  two  diseases  being  entire- 
ly distinct.  The  same  may  be  said  of  the  third  disease,  the 
non-infecting  chancre.  From  what  precedes  it  may  be  con- 
cluded that  a  man  can  contract  urethritis  from  a  woman  who 
has  a  chancre,  chancroids,  or  mucous  patches  of  the  geni- 
tals. Many  experienced  and  sound  observers  have  encoun- 
tered cases  of  urethritis  so  contracted,  and  the  patients  have 
not  had  the  slightest  indication  of  chancre  or  chancroids. 
CuUerier  thus  explains  the  phenomenon  :  In  the  primitive 
ulcer  there  are  two  things — a  phlegmasic  product  and  some- 
thing special ;  therefore  the  individual  may  take  that  only 
which  is  simply  phlegmasic  and  escape  syphilitic  or  chan- 
croidal infection,  the  pus  acting  only  as  an  irritant.  He 
quotes,  from  Benjamin  Bell's  work,  the  case  of  a  medical 
student  who  placed  some  chancrous  pus  between  the  glans 
penis  and  prepuce,  and  this  caused  a  simple  balanoposthitis, 
while  others,  after  introducing  chancrous  pus  into  the  ure- 
thra, had  only  non-virulent  urethritis. 

It  has  happened  that,  from  the  same  woman,  a  man  has 
contracted  a  chancre  on  the  glans  penis,  and  nothing  else, 
and  that  another  man,  almost  immediately  after,  has  only 
caught  a  simple  urethritis.  It  has  also  happened  that  a 
man  has  contracted,  from  one  woman,  a  "  gonorrhoea,"  an 
infecting  chancre,  and  non-infecting  chancres ;  the  woman 
being  affected  with  all  three  diseases. 

It  may  now  be  said  that  the  proposition,  contained  in 
the  answer  to  the  question  respecting  the  nature  of  ure- 
thritis, is  sustained  and  may  be  summed  up  as  follows  :  Ure- 


200 


thritis  may  be  non-contagious,  it  may  be  contagious  and 
non-infecting,  or  it  may  be  due  to  tbe  presence  in  the  ure- 
thra of  an  infecting  or  of  a  non-infecting  chancre,  and  the 
same  patient  may  contract  a  non-infecting  urethritis  simul- 
taneously with  a  chancre  or  a  chancroid  in  the  urethra. 
This  may  have  happened  in  the  case  cited  by  Hunter  to 
prove  the  identity  of  the  two  diseases. 

Causes. — Urethritis  is  said  to  be  infecting  when  due  to 
the  presence  of  an  infecting  chancre  or  of  a  mucous  patch 
in  the  urethra.  It  is  non-infecting  when  owing  to  a  ure- 
thral chancroid.  It  is  named  virulent  when  it  arises  from 
a  contagium  capable  of  reproducing  itself  indefinitely  under 
proper  conditions,  as  exemplified  in  the  cases  of  urethritis 
commonly  designated  "  gonorrhoea,"  contracted  from  viru- 
lent vulvitis  or  vaginitis,  or  by  mediate  contagion.  It  is 
called  simple  when  non-contagious,  whether  originating 
from  sexual  commerce  or  from  local  irritants. 

Infecting  urethritis  is  followed  hy  distinct  manifestations 
of  syphilitic  infection  in  the  course  of  from  six  weeks  to 
three  months.  The  physicians  who  judge  from  observation 
of  the  effect  of  chancre  at  the  urinary  meatus  deny  that 
urethritis  is  produced  by  urethral  chancre,  for  in  such  cases 
there  is  little  if  any  tendency  to  the  backward  extension  o£ 
the  phlegmasic  action,  which  is  commonly  of  short  duration, 
and  the  mucous  membrane  of  the  urethra  behind  the  sore 
remains  intact.  That  a  chancre  seated  within  the  urethra 
does  produce  urethritis  was  exemplified  by  John  Hunter's 
well-known  experiment.     The  urethritis  caused  by  a  ure- 


201 

thra]  chancre,  besides  generally  being  slight  and  of  short 
duration,  is  accompanied  by  little  or  no  pain  during  urina- 
tion. A  case  of  urethritis  which  gets  well,  without  treat- 
ment, in  a  week  or  in  two  weeks,  needs  to  be  viewed  with 
suspicion  and  to  be  kept  under  close  observation  for  at  least 
three  months. 

The  following  is  given  in  illustration  of  the  clinical  his- 
tory of  a  case  of  infecting  urethritis  :  The  patient,  finding 
it  necessary  to  invoke  medical  assistance  owing  to  certain 
symptoms  which  had  caused  him  some  anxiety,  gave  a  part 
of  this  account  of  his  complaint.  Three  months  before  he 
had  contracted  for  the  first  time  what  he  supposed  to  be  an 
ordinary  urethritis  which  gave  him  very  little  inconven- 
ience and  was  well  in  a  week.  He  had  never  had  any  other 
venereal  disease.  There  was  no  visible  sore  or  scar  upon 
any  part  of  his  sexual  organs.  In  the  course  of  six  weeks 
after  the  cessation  of  the  urethral  discharge  he  had  a  well- 
marked  roseola,  which  was  observed  by  a  medical  officer  of 
the  navy,  and  in  six  weeks  more — that  is,  three  months  after 
the  disappearance  of  the  urethritis,  when  he  applied  for 
treatment — he  was  suffering  from  mucous  patches  in  the 
fauces,  and  showed  other  unmistakable  symptoms  of  syphi- 
lis. When  this  supposed  simple  urethritis  began  he  was  at 
sea  (had  sailed  from  New  York  several  days  before),  and 
for  the  next  eighty  days  was  on  board  a  man-of-war  and  in 
no  way  exposed  to  the  contagion  of  syphilis.  Assuming 
the  veracity  of  the  patient's  story,  it  is  fair  to  conclude  that 
his  urethritis  was  caused  by  an  intra-urethral  chancre. 

Urethritis  due  to  mucous  patches  in  the  urethra,  though 


202 


of  rare  occurrence,  has  been  repeatedly  verified  by  careful 
observers.  It  is  cliaracterized  by  a  discharge  which  is  at 
times  sanious  and  which  continues  as  long  as  the  mucous 
patches  exist.  During  urination  there  is  some  scalding  pain. 
A.  patient  who  has  never  contracted  urethritis,  but  after  im- 
pure sexual  commerce  becomes  infected  with  syphilis  and, 
several  months  after  the  initial  lesion,  is  affected  with  mu- 
cous patches  in  the  fauces  and  a  purulent  sanious  urethral 
discharge,  may  fairly  be  regarded  as  suffering  from  ure- 
thritis due  to  the  existence  of  urethral  mucous  patches,  pro- 
vided that,  in  the  mean  time,  he  had  abstained  from  sexual 
commerce. 

Non-infecting  urethritis  due  to  urethral  chancroids  is  not 
followed  by  lesions  such  as  those  which  characterize  the  in- 
fecting, syphilitic  variety,  but  it  has  its  own  special  virus 
which  acts  locally  and  possesses  the  property  of  reproduc- 
ing itself  indefinitely  in  proper  soils.  The  same  observers 
who  deny  that  urethral  chancre  produces  urethritis  also 
assert  that  chancroids  do  not  give  rise  to  this  phlegmasia, 
and  probably  for  the  same  alleged  reason.  That  chancroids 
of  the  urethra  do  cause  urethritis  is  a  fact  which  few  physi- 
cians now  dispute.  These  chancroidal  ulcers  are  prolific 
sources  of  cicatricial  strictures  in  the  fossa  navicularis  and 
even  in  the  phallic  region  of  the  urethra.  Chancroidal  ure- 
thritis continues  until  the  ulcer  is  healed  and  sometimes 
long  after  the  healing  process.  The  discharge  is  often  pro- 
fuse and  sanious.  When  a  doubt  arises  as  to  its  nature,  the 
question  is  decided  by  inoculating  with  it  the  patient. 

By  virulent  urethritis^  improperly  styled  '■'■  gonorrho&a^'' 


■      203 

is  meant  the  urethritis  resulting  from  sexual  contact  with  a 
person  suffering  from  a  species  of  vaginitis  or  vulvitis  char- 
acterized by  a  purulent  discharge  capable  of  reproducing 
itself,  even  when  applied  artificially  to  any  of  the  mucous 
membranes  that  are  susceptible  to  venereal  phlegmasia. 

The  mucous  membranes  which  are  most  susceptible  to  ve- 
nereal phlegmasia  are  those  of  the  glans  penis,  the  prepuce, 
the  urethra,  the  prostatic  utricle,  the  urethral  crypts,  the 
anus,  the  mouth,  and  the  conjunctiva. 

The  mucous  membranes  which  are  refractory  to  venereal 
phlegmasia  are  those  of  the  ducts  of  the  bulbo-urethral 
glands,  the  prostatic  ducts,  the  ejaculatory  ducts,  the  semi- 
nal vesicles,  the  spermatic  canals,  the  bladder,  the  rectum, 
the  nose,  and  the  lacrymal  canals. 

Bonnieres,  who  has  compared  the  histological  characters 
of  these  two  groups  of  mucous  membranes,  describes  the 
first  as  being  supplied  with  papillae  and  covered  with  pave- 
ment epithelium,  with  an  underlying  network  of  lymphatic 
capillaries  whose  parietes  are  constituted  by  epithelial  cells, 
while  the  second  group  is  covered  by  cylindrical  epithelium 
with  an  underlying  network  of  red  blood-capillaries  instead 
of  lymphatics,  and  concludes  that  the  venereal  phlegmasia 
acts  primarily  upon  the  lymphatic  capillaries  and  the  epi- 
thelium, and  that  the  phlegmasia  of  the  neighboring  tissues 
is  only  secondary  thereto.  In  the  prostatic  region,  for  in- 
stance, there  is  a  close  subepithelial  network  of  lymphatic 
capillaries  which  anastomose  with  the  lymphatic  capillaries 
of  the  spongy  portion  of  the  urethral  mucous  membrane 
and  terminate  abruptly  at  the   urethro-vesical  orifice,  the 


204 

bladder  mucous  membrane  being  entirely  destitute  of  lym- 
phatics ;  hence  it  is  that  the  bladder  is  refractory  to  phleg- 
masia such  as  might  otherwise  be  propagated  through  the 
urethra  (Perrin). 

The  Nature  of  the  Contagium  of  Urethritis. — 
It  has  been  asked  what  evidence  is  offered  in  support  of 
the  assertion  that  there  is  such  an  affection  as  a  sui-generis 
virulent  contagious  urethritis  ?  Many  writers  have  endeav- 
ored to  answer  this  question ;  among  them,  Dr.  Thiry,  of 
Brussels,  and  Mr.  Hutchinson,  of  London. 

Dr.  Thiry  enumerates  three  kinds  of  urethritis — the 
first,  simple ;  the  second,  syphilitic ;  and  the  third,  ha^dng 
a  virus  of  its  own  which  he  calls  the  granulous  virus,  and 
which,  he  says,  is  the  distinctive  character  of  true  conta- 
gious urethritis  whose  morbid  elements  are  granulations. 
But  granulations  exist  in  the  vagina  and  cervix  uteri  in 
many  women  who  seldom  give  urethritis  to  men  who  are 
accustomed  to  lie  with  them  or,  to  use  Ricord's  expression, 
whose  genital  organs  are  acclimated.  This  fact  is  unde- 
niable, and  overthrows  Dr.  Thiry's  doctrine.  If  Dr.  Thiry's 
views  were  correct,  urethritis  should  be  the  rule  and  not  the 
exception  in  these  cases. 

According  to  Mr.  Hutchinson,  the  contact  of  dead  pus, 
whose  corpuscles  are  in  an  advanced  state  of  fatty  degenera- 
tion, such  as  that  from  an  abscess,  causes  but  little  irritation, 
while  living  pus,  recently  formed,  is  contagious  and  likely 
to  cause  phlegmasia  when  in  contact  with  tissues  similar  in 
structure  to  those  whence  it  originated.     But  this  also  fail 


205 


to  establisli  tlie  cliaracter  of  the  contagium  said  to  be  pecul- 
iar to  non-infecting  contagious  urethritis.  In  accordance 
with  the  light  thrown,  of  late  years,  upon  phlegmasic  pro- 
cesses, pus  consists  of  dead  leucocytes  that  have  failed  to 
destroy  the  morbific  materials  they  have  attacked  ;  there- 
fore there  are  no  living  pus-corpuscles.  Pus  is  a  dead 
substance  to  be  ejected  or  encysted  and  rendered  innocuous 
until  transformed.  That  urethritis  is  often  contagious  is 
fully  and  frequently  demonstrated  clinically.  A  man  af- 
fected with  acute  non-infecting  virulent  urethritis  who  de- 
posits his  urethral  pus  into  the  healthy  vagina  of  a  woman 
contaminates  this  vagina,  and  there  follows  vaginitis,  and 
this  same  vaginitis  causes  urethritis  in  another  man  who  ex- 
poses himself  to  the  contagion.  What,  then,  is  the  element 
of  contagion,  and  where  does  it  reside  ?  Is  it  in  the  pus-cell, 
in  the  serum  of  the  pus,  or  in  the  mucus  contained  in  the 
morbid  discharge  ?  These  questions  have  not  yet  been  sat- 
isfactorily answered,  although  several  theories  have  been 
advanced  respecting  the  nature  of  the  contagium,  the  latest 
being  the  microbic. 

Among  those  who  regard  the  contagium  of  urethritis  as 
microbic  is  Dr.  F.  P.  Jousseaume,  who,  in  his  inaugural 
thesis  on  the  vegetable  parasites  of  man,  Paris,  1862,  de- 
scribes an  alga  of  urethritis,  to  which  he  gives  the  name  of 
genitalia,  and  whose  habitat,  he  says,  is  subepithelial.  He 
believes  urethritis,  as  well  as  vaginitis,  to  be  caused  by  the 
presence  of  this  parasite.  This  is  here  recorded  only  as  a 
part  of  the  history  of  the  doctrines  relating  to  the  con- 
tagium of  urethritis. 


206 


Many  of  the  modern  patho-histologists  assert  that  in 
the  discharge  of  simple  urethritis  no  micro-organisms  are 
present,  while  in  non-infecting  virulent  urethritis,  "  gonor- 
rhoea," the  pus-cells  contain  a  specific  diplococcus,  named 
"  gonococcus,"  and  discovered  in  the  year  1879  by  Neisser. 
It  is  further  asserted  that  whenever  this  contaminated  pus 
is  conveyed  to  the  urethra  there  follows  a  urethritis  with 
the  reproduction  of  the  "  gonococcus  "  in  the  pus-cells  of 
the  new  urethritis. 

Since  the  announcement  of  Neisser's  discovery  several 
other  organisms  have  been  detected  in  the  pus  of  virulent 
urethritis.  In  some  cases  of  virulent  urethritis  no  "  gono- 
cocci "  have  been  found,  while  in  many  cases  of  non-viru- 
lent urethritis  "  gonococci  "  abound. 

Diplococci  undifferenced  morphically  from  "gonococci" 
have  been  seen  repeatedly  in  pus  from  different  parts  of  the 
body  and  in  abscesses  distant  from  the  genital  and  urinary 
organs  of  patients  in  whom  there  were  no  traces  of  venereal 
disease. 

It  has  been  suggested  that  the  contagium  resides  in  the 
mucus  of  the  urethral  discharge,  with  the  implication  that 
this  contagium  may  be  a  toxalbumin  destructive  to  the 
epithelium.  But  whence  this  particular  toxalbumin  which 
selects  the  genitalia  with  such  nefarious  intent  ? 

Since  several  different  micro-organisms  have  been  found 
in  the  pus  of  urethritis,  may  not  any  or  all  of  these  organ- 
isms be  capable  of  acting  as  irritants,  and  give  rise  to  super- 
secretion  of  mucus,  to  blood  stasis,  plastic  exudation,  the 
emigration    of    leucocytes,    and  exfoliation  of  epithelium ; 


207 

some  irritant  being  essential  to  the  development  of  phleg- 
masia ?  Or  is  the  irritant  of  urethritis  likely  to  be  a  virulent 
ptomaine  ?  This  is  certainly  not  impossible,  since  urethritis 
has  been  experimentally  induced  by  the  injection  of  dilute 
liquor  ammoniae. 

Nothing  so  far  discovered  has  sufficed  to  explain  the 
nature  of  the  contagium  of  that  variety  of  urethritis  mis- 
called "  gonorrhoea." 

By  mediate  contagion  of  urethritis  is  meant  the  trans- 
mission of  the  disease  without  coitus,  but  by  contact  with 
objects  impregnated  with  the  urethral  or  vaginal  discharge  of 
a  diseased  individual.  The  question  of  mediate  contagion  is 
of  great  consequence.  Much  ridicule  has  been  cast  upon  it, 
and  honest  and  veracious  patients  have  often  been  dis- 
credited when  they  have  declared  that  their  urethral  dis- 
charge was  not  the  result  of  sexual  commerce.  Neverthe- 
less, the  possibility  of  contracting  contagious  urethritis 
mediately — that  is  to  say,  without  sexual  approach — is  a 
fact  which  has  been  attested  by  excellent  observers  for  a 
century  past,  and  which  was  recognized  even  in  the  time  of 
Moses,  as  indicated  in  Leviticus,  chapter  xv,  verses  2,  3,  and 
4  :  "  The  man  that  hath  an  issue  of  seed  shall  be  unclean  .  .  . 
when  a  filthy  humor,  at  every  moment,  cleaveth  to  his  flesh 
and  gathereth  there.  Every  bed  on  which  he  sleepeth  shall 
be  unclean,  and  every  place  on  which  he  sitteth."  That 
patients  contract  purulent  ophthalmia  by  using  towels  soiled 
by  a  person  affected  with  contagious  urethritis  or  vaginitis, 
or  by  the  affected  individual  himself  carrying  a  soiled  hand 
to  his  eye,  is  of  constant  occurrence.     What,  then,  is  to  pre- 


208 


vent  contagion  if  this  pus  be  applied  to  the  orifice  of  the 
urethra  instead  of  the  eye  ?  That  in  these  days  patients  do 
contract  urethritis  in  unclean  places  without  sexual  contact 
is  not  a  very  uncommon  occurrence,  and  that  a  healthy  man 
sleeping  in  the  same  bed  with  a  man  suffering  from  con- 
tagious urethritis  is  liable  to  contract  the  disease  is  also  a 
very  reasonable  assertion,  as  it  is  only  necessary  for  an  al- 
most infinitesimal  quantity  of  infected  pus  to  make  its  way 
to  the  urethra  to  insure  contagion,  and  contact  with  freshly 
soiled  bed-linen  during  sleep  is  not  unlikely.  Nurses  af- 
fected with  contagious  vaginitis  or  vulvitis  have  communi- 
cated purulent  ophthalmia  to  infants  in  their  charge  entirely 
through  soiled  hands,  and  in  the  same  way  have  given 
urethritis  to  children.  Contagious  urethritis  engenders  con- 
tagious vaginitis  and  vice  versa.  Such  are  among  the  ways 
in  which  the  disease  is  propagated  and  perpetuated. 

By  simple  urethritis  is  meant  a  phlegmasia  which  has 
no  specific  virus  and  is  not  contagious,  but  which  arises 
from  the  action  of  mechanical  or  chemical  irritants  to  the 
urethral  mucous  membrane,  from  sexual  excesses,  from  mas- 
turbation, etc.  It  is  characterized  by  symptoms  similar  to 
those  of  virulent  urethritis.  It  has  the  peculiarity  that  the 
phlegmasic  process  often  begins  in,  the  prostatic,  membra- 
nous, or  perineal  region  of  the  urethra,  and  gradually  extends 
forward,  and  finally  invades  the  whole  canal,  but  it  also  fre- 
quently begins  in  the  fossa  navicularis,  extends  backward, 
and  is  attended  with  nearly  all  the  complications  and  sequels 
of   the  contaarious  form.     In  some    cases  there    is   much 


209 

febrile  reaction,  and  the  discharge  is  very  profuse  ;  in  other 
cases  the  urethritis  is  superacute,  while  in  the  majority  it 
is  subacute. 

Gouty  patients  are  sometimes  affected  with  a  'purulent 
urethral  discharge,  which  is  often  attended  with  scalding 
sensation  during  urination.  This  discharge  usually  disap- 
pears on  the  cessation  of  the  gouty  symptoms.  In  certain 
cases,  however,  the  discharge  lasts  many  weeks.  Urethritis 
is  frequently  one  of  the  first  manifestations  of  an  attack  of 
gout,  and  thus  shows  itself  each  time  the  patient  is  newly 
attacked  with  "the  gout,"  This  occurs  so  commonly  in 
some  cases  that  the  patients  are  able,  two  days  before,  to 
announce  the  advent  of  a  gouty  seizure,  and  they  base  their 
prediction  upon  the  ardor  urinse,  which  they  had  noticed  as 
so  regularly  preceding  former  attacks.  The  urine  of  these 
sufferers  is  loaded  with  uric-acid  sand,  and  the  ardor  urinse 
is  .caused  by  minute  punctures  inflicted  upon  the  urethral 
mucous  membrane  in  its  whole  extent  by  the  sharp  points 
of  the  iiric-acid  crystals.  The  mucous  membrane  thus 
wounded  yields  more  or  less  blood,  which  passes  away  with 
the  urine,  and  there  soon  follows  a  flow  of  pus  which  does 
not  cease  until  the  urine  is  free  from  crystalline  matter.  It 
sometimes  happens  that  a  number  of  uric-acid  crystals  are 
cemented  together  and  form  concretions  of  various  sizes, 
from  one  to  six  millimetres  in  mean  diameter,  which,  when 
carried  along  in  the  stream  of  urine,  have  been  known  to 
block  up  the  urethra,  cause  retention  of  urine,  and  phleg- 
masia and  even  ulceration  of  the  urethral  mucous  mem- 
brane. Several  such  concretions  have  been  found  lodged 
14 


210 


behind  urethral  strictures,  causing  retention   of  urine,  be- 
sides a  copious  purulent  collection. 

Stone  in  the  bladder,  particularly  the  phosphatic,  is  some- 
times an  indirect  cause  of  urethritis.  The  ammoniacal  urine 
loaded,  in  such  a  case,  with  prismatic  crystals,  being  ex- 
tremely irritating  to  the  urethral  mucous  membrane,  at 
length  causes  a  urethritis  which,  though  subacute,  is  at- 
tended with  inordinate  sensitiveness  of  the  canal. 

Urethritis  is  known  to  arise  from  the  ingestion  of  sub- 
stances which,  being  eliminated  by  the  kidneys,  render  the 
urine  acrid  and  irritating.  For  example,  the  free  and  con- 
tinuous use  of  asparagus  as  an  article  of  food  is  not  an  un- 
Bommon  cause  of  urethral  phlegmasia.  There  are  many 
persons  who  can  not  make  use  of  this  succulent  delicacy  for 
two  or  three  consecutive  days  without  being  inconvenienced 
by  a  very  considerable  smarting  sensation  in  the  urethra 
during  urination,  and  even  by  a  purulent  urethral  discharge. 
Soon  after  eating  asparagus,  their  urine  emits  a  character- 
istic strong  odor,  and  often  contains  innumerable  crystals 
of  oxalate  of  calcium,  and  this  continues  so  long  as  they 
persist  in  indulging  their  desire  for  this  luxury. 

Among  the  many  who  have  complained  of  the  ill  effects 
of  asparagus  is  a  young  man  who,  during  three  consecutive 
summers,  was  annoyed  by  profuse  urethral  suppuration  with 
much  scalding  in  urination.  On  each  occasion  he  believed 
himself  affected  with  contagious  urethritis,  from  which, 
however,  he  had  never  suffered,  but  during  these  periods  he 
had  been  indulging  very  freely  in  asparagus.  He  was  ad- 
vised to   abstain  from  this  his  favorite  dish,  and  the  dis- 


211 


charge  always  ceased  soon  after  his  compliance  with  the 
advice. 

New  ale^  beer,  cider,  and  other  fermented  liquors,  even 
when  used  in  moderation,  are  known  to  excite  urethritis. 
These  beverages  exert  an  evil  influence  upon  the  imperfect 
digestion  of  elderly  men,  and  their  use  should  be  forbidden. 
The  abuse  of  all  alcoholic  stimulants  is  a  potent  factor  in 
the  production  of  urethritis. 

Free  doses  of  cantharides  given  ignorantly  or  with  ma- 
licious intent  have  led  to  the  gravest  consequences  besides  a 
free  flow  of  pus  from  the  urethra.  Large  Spanish-fly  blisters 
applied  to  the  trunk  or  extremities  have  been  followed  by 
the  same  ill  effects. 

Urethritis  may  he  due  to  any  obstruction  which  favors 
stagnation  and  fermentation  of  urine  in  the  bladder.  Those 
patients  who  have  long  suffered  from  obstructed  urination 
caused  by  urethral  stricture  or  prostatic  enlargement,  and, 
in  consequence  thereof,  have  been  obliged  to  urinate  with 
undue  frequency,  nearly  all  suffer  from  urethritis  as  a  result 
of  the  great  irritation  produced  by  putrid,  ammoniacal 
urine. 

Urethral  phlegmasia  is  sometimes  the  outcome  of  fre- 
quent or  of  violent  catheterism.  Sufferers  from  enlargement 
of  the  prostate,  who  are  obliged  to  use  the  catheter  four  or 
five  times  daily  to  relieve  their  bladders,  are,  in  the  begin- 
ning, much  inconvenienced  by  urethritis.  In  some  cases 
the  first  catheterism  excites  an  acute  urethritis  which 
renders  subsequent  catheterisms  painful,  but  as  it  would  be 
unwise  to  suspend  the  use  of  the  instrument,  measures  are 


212 


taken  to  mitigate  the  phlegmasia  and  relieve  the  pain,  and 
they  are  ordinarily  successful.  Many  cases  could  be  cited 
where  the  first  catheterism  caused  acute  urethritis  which,  in 
a  few  days,  yielded  to  rest  and  mild  local  treatment,  and 
did  not  recur  after  the  urethra  had  become  habituated  to 
the  passage  of  the  catheter.  There  are,  however,  many 
cases  in  which  the  urethral  discharge  becomes  chronic  and 
is  maintained  solely  by  the  irritation  to  which  the  catheter 
gives  rise,  notwithstanding  the  most  careful  antiseptic  pre- 
cautions. In  other  cases,  and  unfortunately  they  are  not 
few,  the  patients,  from  an  unwise,  sense  of  economy,  allow 
themselves  to  use  worn-out,  defective,  or  improperly  con- 
structed catheters,  which  seldom  fail  to  cause  local  mischief. 
Others  again,  from  carelessness  or  ignorance,  use  more  or 
less  violence,  or  catheterize  themselves  with  undue  fre- 
quency, and  urethral  phlegmasia,  if  not  a  more  serious  in- 
jury, is  the  almost  invariable  result. 

When  the  external  orifice  of  the  urethra  happens  to  be 
narrower  than  natural,  and  the  patient  is  in  the  habit  of 
catheterizing  himself  frequently  and  clumsily,  there  some- 
times follows  a  phlegmasia  of  the  extremity  of  the  penis, 
with  more  or  less  induration,  which  renders  the  use  of  the 
instrument  difficult  and  distressing.  In  a  patient  so  affect- 
ed, the  induration  had  involved  such  a  considerable  portion 
of  the  glans  penis  that  it  was  at  first  suspected  to  be  of 
a  malignant  nature ;  but,  after  the  more  careful  use  of  a 
smaller  catheter  and  the  local  application  of  acetate- of- lead 
solution,  the  induration  subsided,  and  the  meatus  was  incised 
so  as  to  allow  the  easy  passage  of  ordinary-sized  catheters. 


213 

Exploring  catheterism,  even  with  a  sterilized  instrument, 
may  cause  urethritis.  Tlae  following  is  a  fair  illustration 
of  this  point :  A.,  sixty-five  years  of  age,  who  applied  for 
treatment  on  account  of  an  attack  of  acute  urethritis,  with 
copious  purulent  discharge,  and  was  not  as  frank  and  out- 
spoken as  a  patient  should  be  with  his  medical  adviser,  be- 
trayed so  much  anxiety  as  to  the  probable  cause  of  his  ail- 
ment and  asked  questions  of  such  character  as  to  lead  his 
hearer  to  the  surmise  that  he  might  have  exposed  himself 
to  contagion.  However,  after  the  summing  up  of  a  con- 
siderable amount  of  cross-questioning,  this  did  not  seem 
likely.  At  length  it  was  incidentally  learned  that  he  had 
been  catheterized,  with  due  precaution,  a  few  days  before, 
with  a  view  of  discovering  the  cause  of  obstruction  to  uri- 
nation, of  which  he  had  been  complaining.  The  instrument 
did  not  penetrate  the  urethral  canal  more  than  two  inches, 
and  in  two  days  the  discharge  of  pus  had  begun.  A  cau- 
tious exploration  revealed  a  very  narrow  stricture  in  the 
phallic  region  of  the  urethra,  and  the  conclusion  arrived  at 
was  that,  if  the  patient  had  illicitly  indulged  his  sexual  de- 
sire, he  surely  had  not  contracted  virulent  urethritis,  but 
that  the  acute  phlegmasia  was  the  result  of  the  catheterism 
perhaps  violently  practiced  upon  an  already  diseased  and 
sensitive  urethra.  The  discharge  ceased  a  few  days  after 
the  urethra  was  properly  enlarged. 

Foreign  bodies  of  various  kinds  introduced  from  without 
into  the  urethra  and  retained  for  a  certain  length  of  time  give 
rise  to  urethritis.  Among  these  foreign  bodies  may  be 
mentioned  broken  ends  of  catheters  or  bougies,  fragments 


214 


of  wood  or  straw,  pudendal  hairs,  and  many  other  objects. 
Several  cases  of  urethritis  caused  by  the  accidental  passage 
of  pudendal  hairs  into  the  urethra  have  been  observed,  the 
purulent  discharge  ceasing  soon  after  the  removal  of  these 
foreign  bodies  from  the  fossa  navicularis  urethrfe. 

A  catheter  retained  a  few  days  in  the  urethra  excites 
phlegmasia  of  the  mucous  membrane,  and  has  been  known 
to  cause  ulceration  at  certain  points,  such  as  the  navicular 
fossa,  the  peno-scrotal  junction,  and  the  bulbo-membranous 
region,  particularly  in  those  cases  of  urethral  stenosis  treated 
by  continuous  dilatation  where  the  instrument  is  sometimes 
unwisely  retained  a  week  or  two  weeks. 

Sexual  excess  appears  to  he  the  most  common  cause  of 
urethral  phlegmasia.  Fournier  expresses  the  opinion  that 
by  excessive  sexual  indulgence  men  give  themselves  ure- 
thritis oftener  than  they  receive  it.  He  further  asserts  that 
seventy-five  per  cent,  of  all  cases  of  urethritis  are  non- 
contagious. The  majority  of  women  from  whom  urethritis 
is  supposed  to  have  been  contracted  had  not  vaginitis  or, 
at  least,  had  not  contagious  vaginitis  or  vulvitis.  The  ure- 
thritis so  developed  is,  of  course,  simple,  non-contagious. 
There  are  women  whose  vulvar  and  vaginal  secretions  are 
so  acrid  as  to  give  urethritis  to  all  those  that  have  sexual 
commerce  with  them.  A  case  often  quoted  in  illustration 
of  this  point  is  that  of  a  noted  and  very  attractive  cour- 
tesan, whose  genital  organs  were  in  a  perfectly  healthy  state, 
but  who,  nevertheless,  gave  urethritis  to  all  the  men  who 
won  her  favor. 

The  occurrence  of  urethritis  from  sexual  contact  during, 


215 


immediately  before,  or  too  soon  after,  the  menstrual  flow,  or 
during  the  early  period  of  lochia!  discharges,  has  been  very 
frequently  verified,  and  such  urethritis,  although  ordinarily 
naild,  is  often  as  obstinate  as  it  is  severe,  and  is  sometimes 
followed  by  many  of  the  evils  of  virulent  urethritis,  but  it 
is  never  contagious. 

Urethritis  is  often  caused  by  sexual  contact  ivith  persons 
suffering  from  leucorrhoea,  or  from  uterine  cancer,  or  tuber- 
culosis. Excessive  sexual  indulgence  with  a  woman  affected 
with  leucorrhoea  is  likely  to  cause  urethritis  in  the  man,  who, 
when  he  discovers  his  infirmity,  is  too  apt  to  accuse  of  infi- 
delity his  partner  in  the  sexual  debauch.  This  has  fre- 
quently happened  in  the  case  of  the  newly  married  and  has 
led  to  connubial  infelicity,  to  much  misery,  to  ill  treatment 
of  the  innocent  wife,  to  divorce,  and  to  utter  ruin.  Other 
sad  consequences,  particularly  to  an  oversensitive  man  who 
may  have  been  suffering  from  an  old  gleet,  are  self-accusa- 
tion, despondency,  and  perhaps  even  suicide,  under  the  er- 
roneous impression  that  he  had  infected  his  wife  with  a 
"  disease  of  which  he  was  not  properly  cured."  It  is  al- 
most needless  to  say  that  chronic  urethritis  is  not  contagious. 

The  following  case  illustrates  another  point  of  medical 
and  legal  interest.  A  medical  man  who  had  been  under 
treatment  for  faucial  diphtheria  went  away  alone  for  a  few 
months,  and  shortly  after  his  return  called  to  say  that  he 
had  urethritis,  from  which  he  had  never  before  suffered. 
In  two  weeks  he  was  well  without  having  had  recourse  to 
the  ordinary  internal  treatment.  The  urethra  was  daily  ir- 
rigated with  mild  astringent  solutions,  and  a  glass  of  Vichy 


216 

water  was  taken  thrice  daily.  It  was  ascertained  that  his 
wife  had,  at  the  time  and  long  before,  been  suffering  from 
leucorrhoea,  and  that  such  was  the  cause  of  the  urethritis 
which  had  attacked  the  husband.  In  a  year  after  this  the 
wife  went  on  a  visit  to  her  relatives  in  the  country.  On  her 
return  in  three  months  her  husband  became  affected  with 
urethritis,  and  again  on  a  third  similar  occasion.  This  last 
did  not  so  rapidly  yield  to  treatment,  though  it  was  milder 
than  the  first  two  attacks.  The  wife  had  so  far  refused  to 
submit  to  treatment ;  at  length,  consenting,  she  was  relieved 
of  her  local  affection,  and  her  husband  never  again  contract- 
ed urethritis  even  after  an  absence  of  several  months.  A 
point  of  much  interest  in  the  case  is  that  after  recovery  from 
each  of  the  attacks  of  urethritis  the  patient  had  no  trouble 
until  the  first  sexual  approach  several  months  after  a  forced 
separation  from  his  wife.  The  case  corroborates  the  asser- 
tion of  Kicord  in  regard  to  what  he  terms  "  acclimation  "  of 
the  genitals. 

That  some  men  are  less  susceptible  to  urethritis  than 
others  is  a  fact  which  careful  observers  have  repeatedly  veri- 
fied. Of  two  men,  of  the  same  age  and  of  equally  sound 
body,  indulging  themselves  sexually,  within  two  or  three 
hours,  with  the  same  woman,  untouched  meanwhile  by  oth- 
ers, one  has  escaped  unharmed  while  the  other  has  con- 
tracted urethritis.  In  some  instances  it  happens  that  the 
first  becomes  diseased  ;  in  other  cases  it  is  the  second  that 
becomes  affected. 

Men  contract  urethritis  from  women  suffering  from  ma- 
lignant or  from  tubercular  ulceration  of  the  cervix  uteri. 


217 

That  women  affected  witti  ulcerated  uterine  epitheliomata, 
emitting  acrid  discharges,  give  urethritis  to  their  husbands, 
is  a  fact  which  bears  the  attestation  of  physicians  of  exten- 
sive experience.  The  discharge  from  tubercular  ulceration 
of  the  uterus  is  not  only  capable  of  causing  urethritis,  but 
of  producing  tuberculosis  of  the  urethra.  Some  cases  of 
tuberculosis  of  the  male  genital  organs  have  been  traced  to 
this  cause. 

Masturbation  as  a  cause  of  urethritis  requires  more  than 
a  passing  notice.  Those  addicted  to  the  vice  of  masturba- 
tion are,  in  consequence,  attacked  with  urethritis  with  great- 
er frequency  than  is  generally  supposed.  This  urethritis 
usually  has  the  characters  of  chronicity  from  the  outset,  and 
the  discharge  is  so  slight  that  it  at  first  escapes  observation, 
or  otherwise  it  is  thought  to  be  of  little  consequence  by  the 
patient,  the  sensitiveness  of  whose  urethra  has  perhaps  been 
blunted  by  long- continued  abuse;  hence  the  many  cases  of 
stricture,  the  origin  of  which  is  not  satisfactorily  traced,  ex- 
cept by  those  physicians  whose  attention  has  been  fixed  upon 
such  cases  and  who  have  been  able  to  extract  the  truth  from 
patients  regarding  early  habits  of  masturbation.  The  com- 
mon story  of  these  patients  is  that  they  had  noticed  a  con- 
stant urethral  discharge  which  they  had  regarded  as  diurnal 
emissions  of  semen.  In  rare  cases  this  urethritis  becomes 
acute  and  even  superacute. 

Almost  any  sort  of  mechanical  irritation  of  the  urethra  is 
likely  to  lead  to  phleymasic  action.  Infant  boys  sometimes 
suffer  much  from  urethritis  by  being  fingered  by  vicious 
nurses  desiring  to  gratify  their  own  depraved  instincts,  or, 


218 


as  they  often  pretend,  "  to  prevent  the  child  from  crying." 
Young  boys  are  not  infrequently  attacked  Avith  urethritis 
during  dental  evolution,  or  during  affections  which  lead  to 
errors  in  nutrition,  the  consequent  hyperlithuria  being  the 
chief  factor  in  the  causation  of  the  urethritis. 

Urethritis  occurring  in  elderly  men  is  often  a  source  of 
much  anxiety  and  suffering.  A  question  often  asked  is,  To 
what  extent  are  elderly  men  liable  to  urethral  phlegmasia, 
and  does  this  differ  from  the  urethritis  of  youth ;  if  so,  in 
what  particulars  ?  This  question  may  thus  be  answered : 
While  urethritis  is  generally  simple,  non-contagious,  among 
elderly  men,  and  is  less  frequent  than  among  young  and 
middle-aged  men,  it  can  not  be  regaided  as  an  infrequent 
affection  in  advanced  life.  For  instance,  it  occurs  to  a 
greater  or  less  extent  in  a  very  considerable  proportion  of 
cases  of  enlargement  of  the  prostate,  and  or  travel  and 
stone  in  the  bladder.  It  is  not  denied  that  elderly  men  are 
sometimes  affected  with  contagious  urethritis,  for  some 
among  them  are  so  unwise  as  to  expose  themselves  to  con- 
tagion, but  happily  they  are  comparatively  few,  and  those 
who  commit  sexual  excesses  are  not  many.  Urethritis  is 
generally  not  so  violent  in  elderly  men  as  in  youth  or  mid- 
dle life.  Only  very  exceptionally  is  it  severe  in  the  acute 
type,  and  it  is  very  rarely  superacute.  Most  frequently  it 
is  subacute  and  soon  passes  into  the  chronic  state.  It  is 
characterized  by  less  pain,  less  ardor,  less  dysuresis,  and 
generally  less  purulent  discharge  than  in  youth,  but  it  is 
more  persistent  and  less  amenable  to  treatment.  In  youth, 
in  the  great  majority  of  cases,  urethritis  begins  in  the  an- 


219 


terior  extremity  of  the  urethra,  while  in  advanced  life  it 
very  often  begins  at  the  posterior  extremity  or  at  once  in- 
vades the  whole  canal. 

Diagnosis. — For  diagnostic,  prognostic,  and  therapeutic 
purposes  it  is  essential  to  bear  in  mind  the  following  points  : 
Contagious  non-infecting  urethritis,  "  gonorrhoea,"  and  sim- 
ple non-contagious  urethritis  may  be  benign,  subacute, 
acute,  or  superacute,  and  may  be  primitive,  in  cases  where 
the  urethra  was  never  before  diseased,  or  secondary  in  cases 
where  the  urethra  had  been  the  seat  of  phlegmasia  at  some 
more  or  less  remote  time.  Primitive  contagious  urethritis 
is  said  to  incubate  from  four  to  seven  or  even  fourteen 
days,  while  primitive  simple  urethritis  has  a  very  short 
period  of  incubation,  and  sometimes  declares  itself  a  few 
hours  after  the  action  of  the  irritant  which  has  been  its 
cause.  Secondary  urethritis,  whether  contagious  or  non- 
contagious, has  also  a  very  short  period  of  incubation. 
Urethritis  ordinarily  begins  in  the  balanic  region  and 
gradually  extends  backward,  sometimes  even  to  the  vesical 
orifice. 

The  adjective  benign,  applied  by  some  authors  to  ure- 
thritis, is  intended  to  signify  a  type  characterized  by  mild 
symptoms,  such  as  a  little  ardor  in  urination,  an  itching 
sensation  in  the  fossa  navicularis,  and  a  slight  mucous  dis- 
charge, all  of  which  disappear  in  a  few  days.  Though  be- 
nign urethritis  may  thus  rapidly  resolve,  it  is  frequently  in 
reality  the  first  stage,  the  close  of  the  period  of  incubation 
of  the  other  types.     That  is  to  say,  what  for  three  or  four 


220 


days  may  appear  to  be  a  simple  benign  urethritis  may  be- 
come a  subacute,  an  acute,  or  a  superacute  urethritis,  or  the 
discharge  may  become  slightly  purulent  and  persist  as  a 
chronic  urethritis. 

Subacute  urethritis  is  characterized  by  a  free  muco-puru- 
lent  discharge  with  but  little  redness  of  the  urinary  meatus 
and  slight  scalding  sensation  in  urination.  Its  periods  of 
increase,  stasis,  and  decline  are  sometimes  all  ill  defined  or 
scarcely  perceptible.  Resolution  occurs  in  from  four  to  five 
weeks,  or  the  discharge  lessens,  but  persists  and  becomes 
chronic. 

Acute  urethritis,  as  before  stated,  begins  as  benign  ure- 
thritis, which  is  its  first  stage,  lasting  three  or  four  days. 
After  this  the  discharge  becomes  purulent  and  soon  thickens 
into  a  creamy  state,  yellowish  at  first  and  later  greenish 
from  an  admixture  of  blood ;  the  phlegmasic  action  daily 
augmenting  until  about  the  tenth  day,  when  it  reaches  its 
maximum  of  intensity.  During  this  time  there  is  much 
scalding  in  urination,  the  lips  of  the  meatus  are  red  and 
pouting,  and  nocturnal  erections  of  the  penis  are  frequent 
and  painful.  This  is  the  second  or  stage  of  increase,  which 
has  been  termed  the  acute  stage  of  acute  urethritis,  the 
adjective  acute  having  already  been  used  to  qualify  the  type 
of  a  phlegmasia.  The  acute  type,  for  instance,  has  its  stages 
of  incubation,  of  increase,  of  stasis,  and  of  decline.  Then 
comes  the  third  stage  or  static  period,  during  which  the 
phlegmasic  process  neither  increases  nor  diminishes.  This 
period  may  be  short,  lasting  one  or  two  days,  or  may  last 
from  seven  to  ten  days.     It  is  followed  by  the  fourth  or 


221 


stage  of  decline,  which  is  the  beginning  of  resolution.  The 
discharge  is  then  thin  and  pale,  ceasing  ordinarily  between 
the  fourth  and  sixth  week.  Among  young  and  healthy  sub- 
jects the  first  acute  urethritis  often  resolves  within  three 
weeks.  In  some  cases  resolution  is  incomplete  and  the  dis- 
charge persists  indefinitely.  The  phlegmasia  is  then  said 
to  have  passed  into  the  chronic  state. 

Superacute  urethritis  is  characterized  by  a  superabundant 
flow  of  pus  mixed  with  blood,  all  the  other  phenomena  of 
acute  urethritis  being  greatly  intensified.  There  is  often 
the  complication  of  balano-posthitis  with  much  oedema  of 
the  prepuce ;  the  whole  penis  is  swollen  and  the  larger 
lymph  vessels  thereof  are  inflamed.  Nocturnal  erections  of 
the  penis  are  almost  uncontrollable,  extremely  painful,  and 
attended  by  what  is  commonly  called  chordee,  which  is  a 
curvation  of  the  distended  penis  toward  the  perinaeum. 
This  curvation  is  caused  by  a  superabundant  plastic  exuda- 
tion in  the  meshes  of  the  submucous  tissue  and  corpus 
spongiosum.  The  corpora  cavernosa  are  gorged  with  blood, 
but,  the  corpus  spongiosum  being  blocked  by  the  exudate, 
complete  erection  of  the  penis  is  impossible.  Retention  of 
urine  is  of  frequent  occurrence  in  this  type  of  urethritis. 
Resolution  is  generally  incomplete,  and  the  exudate  be- 
comes imperfectly  organized,  undergoes  sclerosis,  and  strict- 
ure ensues. 

Chronic  urethritis  is  characterized  by  a  slight  muco- 
purulent discharge,  often  to  the  extent  of  a  few  drops  only 
each  day,  but  this  discharge  is  persistent,  and  increases  in 
quantity  after  a  debauch  or  after  sexual  excess.     Chronic 


222 


urethritis  is  consequent  upon  any  of  the  types  to  wMcJi 
reference  has  been  made,  or  begins  with  the  essential  char- 
acters of  chronic  phlegmasia.  Men  suffering  from  chronic 
urethritis  are  much  more  liable  to  contract  acute  urethritis 
than  those  whose  urethras  are  sound. 

The  site  of  the  urethritis  due  to  chancre,  mucous  patches, 
or  chancroids  is  the  fossa  navicularis,  but  in  rare  instances 
it  has  been  discovered  in  the  phallic  and  even  in  the  peri- 
neal region  of  the  urethra. 

Contagious  non-infecting  urethritis  begins  in  the  fossa 
navicularis,  and  there  remains  stationary  ordinarily  for  sev- 
eral days ;  then,  if  it  do  not  speedily  resolve,  gradually  ex- 
tends itself  as  far  as  the  sinus  of  the  bulb,  there  to  lin- 
ger and  become  chronic,  or  on  the  third  or  even  the 
fourth  week  may  reach  the  urethro-vesical  orifice,  with- 
out, however,  passing  this  limit — a  fact  which  seems  to 
justify  the  assertion  that  acute  urethritis  is  a  spreading 
angeioleucitis,  terminating,  as  it  does,  abruptly  at  the  neck 
of  the  bladder,  beyond  which  no  lymphatics  have  been 
discovered. 

Simple  non-contagious  urethritis,  like  the  contagious, 
often  begins  in  the  fossa  navicularis  and  gradually  extends 
backward,  as  was  so  well  illustrated  by  Swediaur's  experi- 
ment. He  injected  into  his  own  urethra  some  diluted 
liquor  ammonise,  and  soon  thereafter  experienced  the  most 
excruciating  pain,  followed  by  an  acute  urethritis  which  be- 
haved very  much  like  acute  contagious  urethritis  and  lasted 
six  weeks,  beginning  in  the  fossa  navicularis  and  ending  at 
the  urethro-vesical  orifice. 


223 

As  there  are  many  exciting  causes,  so  there  are  many  va- 
rieties in  the  phenomena  of  urethritis.  The  phlegmasia 
may  be  mild  and  transitory,  or  it  may  be  mild  and  per- 
sistent. It  may  be  violent  and  transitory,  or  it  may  be 
violent  and  persistent. 

It  may  begin  and  end  in  the  balanic  and  phallic  regions, 
or  in  the  prostatic  and  perineal  regions,  or  may  invade  the 
whole  canal. 

Its  course  may  be  benign  or  subacute  for  ten  days  or 
two  weeks,  and  suddenly  it  may  assume  the  characters  of 
the  acute  or  of  the  superacute  type.  As  a  general  rule,  this 
sudden  change  is  provoked  by  some  irregularity,  such  as  a 
debauch,  coition,  etc.,  but  sometimes  the  cause  is  not  ap- 
parent. 

The  discharge  throughout  an  attack  of  acute  urethritis 
may  be  purulent  and  creamy,  muco-purulent  and  glairy,  thin 
and  serous,  or  sanious. 

An  acute  urethritis,  at  the  expiration  of  four  or  five 
weeks,  may  seem  to  be  cured,  and  in  a  week  there  may  be 
a  relapse,  all  the  phlegmasic  phenomena  returning.  It  may 
then  again  yield  to  treatment,  and  in  a  week  or  ten  days 
after  the  cessation  of  the  discharge  a  second  recrudescence 
may  occur,  and  this  second  may  be  followed  by  a  third  re- 
lapse. Thus,  the  phlegmasia  may  continue  several  months. 
In  a  case  observed  long  ago  it  lasted  one  year.  The  patient, 
a  medical  man,  from  that  time  suffered  with  cystitis,  of 
which  he  was  not  well  fifteen  years  afterward. 


224 


IX. 

Treatment  of  the  Acute  Types  of  Urethritis. 

Urethritis,  liable  to  divers  accidents,  complications, 
and  consequences,  may  be  regarded  as  a  stricture  in  posse, 
the  germ  of  a  stricture — in  other  words,  urethritis  and  the 
consequent  stricture  may  be  considered  as  a  continuous 
process  whose  evolution  begins  at  the  inception  of  the 
phlegmasic  action  and  ends  with  the  confirmed  stricture. 
Therefore  the  general  indications  of  treatment  of  urethritis 
are — 1,  to  remedy  the  phlegmasia;  2,  to  guard  against  ac- 
cidents and  complications ;  3,  to  prevent  the  formation  of 
stricture ;.  and  4,  to  minister  promptly  to  other  conse- 
quences of  this  phlegmasia.  The  special  indications  vary 
with  the  types,  stages,  and  complications  of  the  affection, 
with  the  peculiarities  and  general  condition  of  the  indi- 
vidual, and  with  his  hygie'nic  environment. 

Abortive  Treatment. — The  treatment  of  acute  urethri- 
tis was  for  a  long  time  based  upon  erroneous  notions  of 
its  nature,  and  directed  to  the  substitution,  as  it  was  be- 
lieved, of  a  simple,  inoffensive,  for  a  specific  phlegmasia. 
This  treatment,  suggested  in  1780  by  Simmons,  and  after- 
ward largely  employed  by  Ricord,  Diday,  and  others,  con- 
sisted of  urethral  injections  of  nitrate-of -silver  solution  (ten, 
fifteen,  or  twenty  grains  to  the  ounce),  and  was  named  the 
abortive,  to  distinguish  it  from  the  methodical  treatment. 


225 

This  supposed  quick  way  was  as  delusive  as  it  was  alluring, 
alike  to  patients  and  to  physicians,  for  it  seldom  cut  short 
the  attack  of  urethritis,  and  besides  the  great  distress  it 
caused,  was  often  productive  of  grave  effects  upon  the 
urethra  and  adjacent  parts,  the  first  effect  being  a  super- 
acute  urethritis,  then  peri-urethritis,  lymphangeitis,  some- 
times prostatitis,  trachelocystitis,  gonecystitis,  orchitis,  etc. 
Inasmuch  as  this  too  heroic  treatment  is  still,  though  very 
rarely,  recommended,  it  was  thought  necessary  to  give  this 
note  of  warning  to  younger  members  of  the  profession 
against  the  employment  of  means  which  not  only  fail  to 
remedy  but  serve  to  aggravate  the  affection. 

Two  other  modes  of  abortive  treatment  were  afterward 
employed:  1.  The  administration  of  balsamics  alone.  2. 
The  balsamics  and  urethral  injections  combined.  They  also 
have  proved  worse  than  useless.  The  balsamics  alone  were 
much  used  by  CuUerier,  who  gave  them  in  very  large  doses. 
He  prescribed  from  twenty  to  fifty  grammes  of  powdered 
cubebs  each  day,  alternating  with  copaiba  balsam,  of  which 
he  gave  from  fifteen  to  twenty  grammes  a  day  in  divided 
doses.  Such  doses  may  for  a  few  days  be  tolerated  by  some 
stomachs,  but  how  fatal  they  must  prove  to  the  faithful  kid- 
neys which  distill  the  active  principles  of  these  drugs  that, 
through  the  urine,  they  may  act  upon  the  diseased  urethra  ! 

The  association  of  astringent  injections  with  balsamics 
was  extolled  by  Ricord  when  nitrate  of  silver  failed.  The 
substances  used  for  these  injections  were  sulphate  of  zinc 
and  acetate  of  lead,  or  the  two  together,  three  and  five  grains 
to  the  ounce,  repeated  three  times  daily. 
15 


226 


Uretlira]  injections  with  copaiba-balsam  emulsion  have 
also  been  used,  but  soon  abandoned  on  account  of  the  great 
ensuing  irritation.  Then  -were  vaunted  many  "infallible 
remedies,"  used  by  mouth  or  applied  by  injection  or 
through  soluble  bougies,  all  of  which  have  done  infinite 
mischief.  These  panaceas  were  generally  prescribed  with- 
out regard  to  the  particular  stage  of  the  phlegmasia. 

A  complete  list  of  the  drugs  given  for,  and  the  modes 
of  treatment  of,  urethritis  that  have  been  used  and  failed 
or  caused  serious  harm  would  more  than  fill  a  large  and 
thick  quarto  volume  printed  in  small  type. 

Methodical  Treatment. — To  treat  urethritis  rationally 
and  methodically,  it  is  necessary  first  to  ascertain  the  na- 
ture, cause,  type,  and  precise  stage  of  the  phlegmasic  at- 
tack, and  the  general  condition  of  the  sufferer. 

Hygienic  Precautions. — From  the  beginning  to  the  end 
of  this  treatment  the  most  rigid  hygienic  precautions  should 
be  taken,  if  only  as  prophylactic  of  accidents  and  conse- 
quences. Among  the  enjoinments  are  continency  and 
avoidance  of  all  manner  of  sexual  excitation  during  the 
treatment  and  for  a  month  after  the  cure,  and  abstinence 
from  foodstufiis  that  may  be  trying  to  the  digestive  process 
or  that  are  likely  to  act  injuriously  through  the  urine,  which 
is  one  of  the  most  important  factors  both  for  ill  and  for  good 
in  urethritis.  For  ill,  when  it  is  excessively  acid  and 
charged  with  acid  phosphates  or  with  uric  acid,  or  when  it 
is  excessively  alkaline  and  loaded  with  triple  phosphates. 
For  good,  when  it  can  be  kept  bland  and  when  it  can  be 


227 


made  the  carrier  of  medicinal  agents.  Therefore  the  phy- 
sician should  keep  a  close  watch  over  the  urine  throughout 
the  treatment  of  urethritis.  The  diet  should  not  otherwise 
be  restricted,  except  in  quantity,  which  may  be  a  little  less 
than  in  health,  but  not  so  decreased  as  to  reduce  the  vital 
powers.  An  already  feeble  patient  is^  benefited  by  a  gen- 
erous diet,  with  even  a  moderate  allowance  of  wine,  and  is 
thus  placed  in  a  condition  to  recover  from  his  urethritis 
much  sooner  than  he  would  under  insuflScient  alimenta- 
tion. 

The  most  scrupulous  cleanliness  should  be  observed. 
The  glans  penis  should  be  bathed  twice  or  thrice  daily  in  a 
solution  of  mercuric  chloride  (one  to  ten  thousand),  and  the 
patient  cautioned  against  carrying  his  hand  to  the  face  or 
near  the  eye  after  touching  the  genitals,  and  to  burn  all 
cloths  that  may  be  impregnated  with  pus.  The  reason  for 
these  precautions  should  be  fully  explained  to  him,  for  they 
are  among  the  most  essential  of  the  hygienic  observances, 
without  which  virulent  ophthalmia  is  almost  certain  to 
ensue. 

The  bed  on  which  he  sleeps  should  not  be  too  soft,  the 
covering  should  be  as  light  as  the  state  of  the  weather  per- 
mits, and  the  room  as  little  heated  as  possible.  This,  in  a 
measure,  tends  to  prevent  erections. 

Much  walking  or  any  prolonged  exertion  should  be 
avoided,  as  either  is  conducive  to  complications  and  conse- 
quences, such  as  oidema  of  the  prepuce,  phimosis,  lymphan- 
geitis,  orchitis,  etc. 

General  Treatment. — The  first  stage  of  urethritis  or,  as 


228 


it  is  called,  benign  urethritis,  whicli  is  tlie  period  of  incu- 
bation of  acute  urethritis,  should  be  treated  with  a  view  of 
favoring  its  early  deliquescence.  Wlien  a  patient  presents 
himself  three  or  four  days  after  a  sexual  debauch,  complain- 
ing of  a  little  ardor  in  urination,  and  has  a  slight  clear  mucous 
urethral  discharge  and  some  congestion  of  the  mucous  mem- 
brane at  and  within  the  meatus,  the  physician — after  inquir- 
ing into  the  circumstances  of  the  debauch,  particularly  if 
the  culprits  had  both  indulged  freely  in  beer,  wine,  or  spirit, 
and  what  was  the  degree  of  sexual  erethism  in  both — is  ready 
to  pass  judgment  upon  the  question  as  to  whether  this  is  or 
is  not  the  beginning  of  an  acute  urethritis.  If  he  has  a 
doubt,  he  should  give  the  patient  the  benefit  of  that  doubt 
by  treating  the  case  as  if  it  were  going  to  be  acute  urethri- 
tis. The  treatment  should  first  be  directed  toward  render- 
ing the  urine  as  inoffensive  as  possible.  If  the  urine  con- 
tains a  great  excess  of  uric  acid,  four  or  five  doses  of  ten 
grains  each  of  sodium  salicylate,  largely  diluted,  should  be 
given  during  the  first  day  only.  Afterward  twenty  grains 
of  sodium  bicarbonate,  also  largely  diluted,  should  be  given 
four  times  daily,  adding  the  juice  of  half  a  fresh  lemon  to 
each  dose,  thus  making  a  citrate  of  sodium,  which  is  better 
tolerated  by  the  stomach  than  the  salicylate.  The  deple- 
tion produced  by  a  brisk  saline  cathartic  (an  ounce  of  sul- 
phate of  sodium)  is  of  much  service  in  this  stage  of  the 
phlegmasia.  Rest  at  this  period  is  of  much  consequence, 
and  may  in  the  end  be  a  great  saving  of  time. 

The  local  treatment  of  the  first  stage  of  urethritis  consists 
of  two  daily  irrigations  of  the  phallic  region  of  the  canal 


229 


witli  a  solution  of  mercuric  chloride  (one  to  ten  thousand, 
or  even  one  to  twenty  thousand).  The  quantity  for  each 
irrigation  should  not  be  less  than  a  pint  of  water  at  a  tem- 
perature of  102°  to  105°  F.  The  greatest  care  should  be 
taken  against  bruising  or  in  any  way  irritating  the  urethra 
during  these  irrigations.  A  smooth,  hollow  bougie  of  gum 
or  glass,  not  over  four  inches  long,  acorn-shaped  at  its  vesi- 
cal extremity,  not  larger  than  No.  10  English,  with  three 
or  four  perforations  at  the  base  of  the  acorn,  may  be  used 
for  the  purpose.  The  bougie,  fastened  to  the  long  India- 
rubber  tube  of  a  fountain  syringe,  is  then  gently  passed 
into  the  phallic  region  of  the  urethra  for  about  two  inches 
and  a  half  and  the  irrigation  begun,  the  retrograde  current 
washing  all  that  part  of  the  urethra  anterior  to  the  acorn, 
and  running  out  into  a  vessel  placed  between  the  thighs  of 
the  patient,  who  should  then  be  sitting  upon  the  edge  of 
his  bed  or  chair.  If  the  irrigations  are  well  tolerated  by  the 
urethra,  and  if  the  urethral  congestion  is  decreased  in  the 
course  of  two  days,  the  treatment  should  be  continued  sev- 
eral more  days  to  insure  deliquescence  of  the  phlegmasia. 
But  if,  on  the  contrary,  the  discharge  increases  and  becomes 
opaque,  showing  the  advent  of  the  second  stage,  the  irriga- 
tions should  at  once  be  stopped,  as  otherwise  they  would 
be  likely  to  cause  superacute  urethritis  and  its  conse- 
quences. 

If,  when  a  patient  first  applies  for  treatment,  the  dis- 
charge, instead  of  being  clear  mucus,  is  already  opaque,  it 
indicates  the  presence  of  pus  and  the  beginning  of  the  sec- 
ond stage.     In  such  a  case  the  local  treatment  by  irriga- 


230 


tious  should  not  be  employed.  The  first  part  of  the  treat- 
ment, i.  e.,  the  citrate  of  sodium,  etc.,  should  constitute 
the  principal  remedial  means. 

Patients  very  rarely  apply  for  treatment  until  the  sec- 
ond stage  of  urethritis  is  fully  established.  It  is  then  that 
meddlesome  treatment  and  polypharpaacy  are  so  often  car- 
ried to  the  greatest  excess,  partly  through  the  solicitation 
of  the  anxious  patient,  partly  owing  to  misinterpretation  of 
the  phenomena  of  urethritis,  and  to  the  vain  search  for^^a 
specific,  and  it  is  then  that  the  misguided  employ  blindly 
those  heroic  means  which  so  surely  lead  to  serious  con- 
sequences. 

Subacute  urethritis,  whose  characters  in  its  second  stage 
are  generally  a  free  purulent  discharge  with  little  exfolia- 
tion of  epithelium,  comparatively  little  pain,  very  little  scald- 
ing in  urination,  and  no  nocturnal  erections,  notwithstand- 
ing its  mildness,  is  persistent  and  requires  careful  manage- 
ment lest  it  become  acute  or  superacute.  In  the  second 
stage  of  subacute  urethritis  the  same  hygienic  precautions 
should  be  taken  as  in  the  other  types,  and  the  same  diluent 
beverages  as  those  used  in  the  first  stage,  only  it  is  wise  to 
vary  the  drink  every  few  days,  substituting  uva-ursi,  buchu, 
or  dog-grass  tea  for  the  citrate  of  sodium,  and  finally  return- 
ing to  the  sodium  citrate.  In  the  subacute,  like  the  other 
types,  balsamics  should  not  be  used  for  several  weeks,  or  not 
until  the  stage  of  decline,  and  should  not  be  given  in  as  large 
doses  ;  nor  should  irrigations  be  employed  until  very  near 
the  close  of  the  period  of  decline,  when  the  discharge  has 
decreased  to  a  few  drops  each  day. 


231 


The  second  or  stage  of  increase,  of  greatest  activity,  of  the 
acute  type  of  urethritis,  during  which  it  is  steadily  extend- 
ing backward,  attended  as  it  is  with  much  pain  in  urination, 
owing  to  extensive  exfoliation  of  the  urethral  epithelium, 
and  with  painful  nocturnal  erections  of  the  penis,  demands 
an  antiphlogistic  medication.  During  this  stage  balsamics 
and  injections  are  worse  than  useless,  and  provocative  of 
complications  and  consequences  which  not  only  retard  the 
cure  but  are  in  themselves  of  grave  import.  They  should 
therefore  under  no  circumstances  be  administered  during 
that  period.  The  amount  of  food  should  for  a  few  days  be 
lessened  ;  a  saline  laxative,  two  drachms  of  sulphate  of  so- 
dium in  six  ounces  of  hot  water,  should  be  given  every  morn- 
ing ;  thirty  grains  of  citrate  of  sodium  four  times  daily  for 
three  or  four  days ;  a  full  bath  of  half  an  hour  at  a  tempera- 
ture of  102°  during  these  four  days,  after  which  a  nightly 
hot  hip  bath  of  five  minutes  is  substituted  ;  and  absolute 
rest.  Four  or  five  times  during  the  day  the  penis  should  be 
dipped,  for  cleansing  and  for  urination,  into  a  small  vessel  of 
warm  mercuric  chloride  solution  (one  to  five  thousand).  To 
combat  the  nocturnal  erections  of  the  penis,  ten  grains  of 
camphor  and  one  grain  of  hyoscyamus  extract  may  be  given 
at  bed-time  and  once  repeated  during  the  night  if  necessary. 
For  a  fidgety  algophobic  patient  a  dose  of  thirty  grains  of 
sodium  bromide  largely  diluted  may  be  given  instead  of  the 
camphor  and  hyoscyamus. 

In  this  second  stage  superacute  urethritis  is  similarly 
treated.  To  relieve  the  excessive  pain  during  erection  and 
chordee,  the  penis  should  be  immersed  in  a  vessel  of  iced 


232 

water,  wherein  the  patient  may  then  urinate  niuch  to  his 
relief,  A  full  dose  of  opium  during  the  day  and  a  rectal 
suppository  of  a  grain  of  opium  and  half  a  grain  of  bella- 
donna extract  at  night  may  be  necessary  to  relieve  pain  and 
induce  sleej).  The  application  of  ten  or  twelve  leeches  to 
the  perinseum  often  has  the  effect  of  relieving  extreme 
pain  and  of  shortening  the  period  of  increase.  This  of 
course  is  advisable  only  in  the  case  of  strong  and  robust 
subjects. 

During  the  third  stage  or  static  period,  this  active  anti- 
phlogistic treatment  is  discontinued.  The  five-minute  hot 
hip  baths  are,  however,  continued.  The  quantity  of  dilu- 
ents is  diminished  or  their  constituents  changed,  and  the 
case  is  otherwise  treated  in  accordance  with  such  new  in- 
dications as  may  arise.  The  static  period  is  generally  of 
short  duration,  and  if  there  be  no  complications  or  con- 
sequences, such  as  will  be  described  later,  the  fourth  stage 
soon  begins. 

The  fourth  stage  or  period  of  decline,  is  ordinarily  the 
beginning  of  resolution,  which  may  be  rapid  and  complete 
in  two  or  three  weeks,  or  slow  and  last  four  or  five  weeks, 
or  incomplete  and  indefinite  and  merge  into  chronic  urethri- 
tis. During  this  period  of  decline  the  phlegmasic  phenom- 
ena are  absent,  and  there  is  only  the  purulent  discharge, 
which  is  less  in  quantity  and  very  perceptibly  altered  in 
quality.  It  is  no  longer  creamy  and  contains  more  mucus 
and  less  epithelium.  There  are  no  painful  erections  of  the 
penis,  and  the  urine  has  ceased  to  cause  scalding  pain.  It 
is  at  this  time  that  the  diluents  should  be  suspended  and 


233 

that  the  balsamics  may  safely  be  administered,  but  not  in 
the  large  doses  so  commonly  given,  such  as  three  drachms 
daily  of  copaiba  balsam  or  one  ounce  of  cubeb  powder. 
Both  of  these  drugs,  thus  given,  vpithin  three  or  four  days 
become  so  nauseating  that  the  most  willing  patients  reject 
them.  In  moderate  doses  they  are  longer  tolerated,  but 
finally  disturb  the  digestive  process  and  have  to  be  aban- 
doned. About  twenty-five  years  ago  sandal-wood  oil  was 
suggested  by  Henderson  as  preferable  to  copaiba.  Since 
then  experience  has  demonstrated  this  superiority,  and  the 
sandal  oil  is  now  much  more  extensively  used  than  copaiba, 
whose  properties  it  possesses  without  its  disadvantages. 
But  even  this  oil  should  not  be  given  in  large  doses.  Two 
capsules,  containing  each  ten  minims  of  sandal-wood  oil, 
may  be  taken  four  times  daily  for  a  week,  then  three  times 
daily  for  another  week,  and  during  the  third  week  the  dose 
should  be  decreased  until  the  patient  shall  have  taken  only 
one  capsule,  when  the  drug  is  discontinued.  There  are  pa- 
tients that  can  not  bear  even  this  comparatively  mild  treat- 
ment. Their  troubles  last  longer,  but  after  all  get  well  with- 
out it. 

Not  until  the  stage  of  decline  is  far  advanced  should 
urethral  injections  be  used,  and  then  only  if  after  the  use  of 
the  balsamics  there  is  still  a  slight  discharge.  Before  this 
time  even  mild  injections  are  liable  to  cause  lymphangeitis 
or  peri-urethritis.  Strong  astringents  should  be  particularly 
avoided.  The  ignorant  believe  that  to  cure  a  urethritis  the 
urethral  mucous  membrane  must  be  practically  tanned.  In- 
jections, to  be  effective,  should  be  used  in  large  quantity, 


234 

but  in  weak,  unirritating  solution,  and  only  once  daily  dur- 
ing this  stage  of  urethritis.  The  small  urethral  syringe 
containing  an  ounce  of  fluid,  used  three  or  four  times  daily, 
does  more  harm  than  good,  for  each  introduction  of  its 
nozzle  is  a  hurt  to  the  urethra.  Among  the  most  efficient 
agents  for  urethral  irrigation  in  these  cases  are  the  corro- 
sive chloride  of  mercury  (1  to  10,000)  and  the  sulphate  and 
chloride  of  zinc.  Of  a  solution  of  sulphate  of  zinc,  half  a 
grain  to  a  grain  to  the  ounce  of  water,  a  pint  is  to  be  used 
at  night  or  in  the  morning  by  means  of  the  simple  apparatus 
and  fountain  syringe  already  described,  except  that  the  hol- 
low bougie  should  be  about  nine  inches  long  in  order  that 
it  may  be  carried  as  far  as  the  sinus  of  the  urethral  bulb  or 
farther  if  necessary,  so  that  the  whole  urethra  may  be 
washed.  The  chloride  of  zinc,  the  other  precious  agent  for 
urethral  irrigation,  should  be  used  in  even  weaker  solution 
than  the  sulphate — from  a  quarter  to  half  a  grain  to  the 
ounce.  In  some  cases  a  solution  of  boric  acid,  two  grains 
to  the  ounce,  suffices  to  cleanse  the  urethra  and  arrest  the 
discharge. 

In  the  majority  of  cases  this  simple  treatment,  which 
can  be  applied  by  the  patient  himself,  answers  well,  and  the 
urethritis  is  cured  in  five  or  six  weeks.  Other  cases, 
whether  complicated  or  uncomplicated,  are  refractory  to 
treatment  and  linger  many  months  or  years.  These  are 
principally  cases  of  secondary  urethritis,  the  patients  hav- 
ing suffered  from  the  phlegmasia  once  or  twice  before,  or 
possibly  being  affected  with  granular  urethritis  or  already 
with  stricture,  or  perchance  with  urethral  mucous  patches 


235 

or  tuberculosis.  The  special  treatment  required  by  these 
cases  will  appear  in  its  appropriate  place. 

Among  the  medicinal  agents  that  have  been  used  in 
Bellevue  Hospital  for  injections  in  urethritis  may  be  men- 
tioned solutions  of  the  violet  methylaniline,  of  permanga- 
nate of  potassium,  of  permanganate  of  zinc,  of  phenol,  of 
hydrastis,  and  many  others,  mostly  vpith  unsatisfactory  re- 
sults. 

As  a  general  rule,  when  uncomplicated  urethritis  is  well 
cured  there  are  no  sequelae.  Some  patients,  however,  suffer 
for  many  months  after  the  cure  from  oversensitiveness  of 
the  urethra,  unduly  frequent  urination,  or  a  superabundant 
mucous  secretion,  due  generally  to  hyperlithuria,  and  de- 
manding a  treatment  appropriate  to  that  condition.  In 
other  cases  a  very  slight  opalescent  urethral  discharge  per- 
sists. In  these  cases  the  careful  introduction  of  a  bulbous 
bougie  reveals  one,  two,  or  three  tender  spots  along  the 
urethra.  These  tender  spots  are.  places  where  there  has 
been  a  greater  degree  of  epithelial  exfoliation  than  else- 
where in  the  canal,  and  the  denuded  spots,  though  after- 
ward covered  with  granulation  tissue,  are  oversensitive 
even  to  the  passage  of  urine,  and  it  is  from  them  that  issues 
the  slight  discharge.  The  treatment  required  is  an  occa- 
sional urethral  irrigation  and  the  introduction,  twice  a  week 
for  two  or  three  months,  of  a  steel  sound  to  dilate  the  canal 
moderately,  to  restore  its  suppleness,  to  destroy  the  granu- 
lation tissue,  to  relieve  the  sensitiveness,  and  to  prevent  the 
formation  of  stricture. 

Conclusions. — The  study  of  the  nature  of  urethritis  and 


236 

of  the  many  modes  of  treatment  proposed  for  its  cure  has 
led  to  the  following  conclusions : 

1.  There  is  no  specific  for  urethritis,  notwithstanding 
the  popular  belief  in  its  existence. 

2.  Urethritis  can  not  rationally  be  dealt  with  as  a  single 
phlegmasic  entity,  no  matter  what  may  be  its  cause. 

3.  The  nature,  course,  and  pathic  properties  of  the  dif- 
ferent stages  of  the  acute  types  of  urethritis  indicate  that 
an  exclusive  method  of  treatment  can  not  be  carried  out  in 
all  cases  with  a  reasonable  prospect  of  success. 

4.  The  treatment  that  is  suited  to  one  type  or  stage  of 
urethritis  is  often  hurtful  in  another  type  or  stage  of  the 
affection. 

5.  The  same  therapeutic  agent,  applicable  to  a  particu- 
lar type  or  stage  of  the  phlegmasia,  is  not  suitable  to  all 
individuals. 

6.  Balsamics  are  contra-indicated  during  the  first  three 
stages  of  urethritis,  and  should  not  be  administered  until 
the  fourth  or  stage  of  decline  is  fully  established. 

v.  Urethral  injections  are  contra-indicated  during  the 
second  and  third  stages  of  urethritis,  but  may  be  used  in 
the  first  stage  and  toward  the  close  of  the  fourth  stage. 

8.  Injections  of  strong  solutions  of  nitrate  of  silver,  or 
of  strong  solutions  of  any  kind,  are  contra-indicated  in  all 
the  stages  of  urethritis. 

9.  Urethritis  is  ordinarily  too  much  and  too  vigorously 
treated.  The  more  heroic  and  meddlesome  the  treatment, 
the  greater  the  liability  to  accidents  and  complications,  and 
the  longer  the  duration  of  the  phlegmasia. 


237 


10.  Confirmed  acute  contagious  urethritis,  under  the 
most  favorable  circumstances  and  the  most  judicious  treat- 
ment, rarely  gets  well  in  less  than  four  weeks,  except  of 
course  in  the  first  attack  in  young-  and  otherwise  healthy 
men  who  are  not  overtreated.  In  the  last-named  cases  it 
sometimes  gets  well  in  ten  days  or  two  weeks  without 
medicinal  treatment. 

11.  Proper  hygienic  management  is  all-important  in  the 
treatment  of  urethritis ;  unless  it  is  rigorously  carried  out, 
the  medicinal  and  local  treatments  inevitably  fail. 


238 


X. 


Accidents,    Complicatioxs,    and    Consequences  of    the 
Acute  Types  of  Urethritis. 

When  exempt  from  accidents,  complications,  and  con- 
sequences, urethritis  resolves  in  four  or  five  weeks,  or,  if 
primitive  and  in  a  young  liealtliy  subject,  may  be  cured  in 
eight  or  ten  days.  It  is  principally  in  this  second  class  of 
cases  that  the  rapid  cures  are  so  frequently  reported, 
while  the  accidents,  complications,  and  consequences  are 
too  often  ranked  by  themselves  as  if  they  had  no  connec- 
tion with  urethral  phlegmasia.  It  is  therefore  necessary, 
in  the  management  of  urethritis,  to  keep  in  mind  the  lia- 
bility of  the  occurrence  of  the  accidents  which  may  arise 
from  the  imprudence,  carelessness,  or  neglect  of  the  patient ; 
of  the  complications  which  aggravate  the  urethral  phleg- 
masia ;  and  of  the  consequences  of  unwise,  untimely,  or 
rash  treatment.  Not  many  years  ago  was  still  in  vogue  the 
routine  treatment  of  "  gonorrhoea,"  consisting  in  the  ad- 
ministration of  large  doses  of  copaiba  or  cubebs,  and  in 
the  use  of  strongly  astringent  urethral  injections,  without 
regard  to  the  type  or  stage  of  the  phlegmasia.  The  fre- 
quency of  accidents  and  of  more  or  less  grave  sequelae  was 
then  great  as  compared  to  what  it  is  at  present.  The 
rational  treatment,  based  as  it  is  upon  a  sounder  pathology 
and  more  accurate  diagnosis,  seems  now  to  be  so  firmly 
established  that  these  accidents  and   sequelse   occur  with 


239 


markedly  less   frequency  than  in  former  times,   and   are 
mucli  better  managed. 

Tlie  accidents  of  acute  urethritis  are  urethral  haemor- 
rhage and  conjunctivitis.  The  complications  to  which 
acute  urethritis  is  liable  are  balanitis,  posthitis,  and  balano- 
posthitis,  the  last  causing  or  aggravating  phimosis,  and  the 
forcible  retraction  of  the  narrowed  and  swollen  prepuce 
producing  paraphimosis.  The  consequences  of  acute  ure- 
thritis are  lymphangeiitis,  inguinal  adenitis,  peri-urethritis, 
•cryptitis,  bulbo-urethral  adenitis,  prostatitis,  orchitis,  gone- 
cystitis,  trachelocystitis,  pyelitis,  nephritis,  septicaemia, 
pyosapraemia,  rheumatism,  chronic  urethritis,  and  urethral 
stenosis. 

Accidents  of  Urethritis. —  Urethral  hcemorrhage  dur- 
ing acute  urethritis  is  ordinarily  due  to  frequent  and  pro- 
longed erections  of  the  penis,  to  masturbation,  or  to  coitus, 
and  is  not  an  uncommon  accident.  It  is  rarely  abundant, 
and  ceases  spontaneously  in  the  majority  of  cases.  Pre- 
ventive and  afterward  repressive  means  should  be  promptly 
employed,  for  the  reason  that  haemorrhage  indicates  here  a 
solution  of  continuity  of  the  mucous  membrane,  and  there- 
fore liability  to  a  rapid  stenotic  process.  Profuse  haemor- 
rhage is  rare  and  generally  due  to  "  breaking  the  chordee  " 
in  superacute  urethritis.  It  usually  ceases  spontaneously 
in  the  course  of  thirty-six  hours,  but  sometimes  continues 
several  days,  much  to  the  detriment  of  the  sufferer.  Active 
measures  should  therefore  be  taken  to  suppress  the  flow  of 
blood.     If  cold  fails  when  applied  externally  or  by  way  of 


240 


intra-urethral  irrigations,  it  is  wise,  witliout  further  delay, 
to  introduce  a  urethroscope  as  far  as  the  seat  of  haemor- 
rhage, to  wash  away  the  blood  with  iced  water,  and  to 
touch  the  bleeding  spot  with  a  camel' s-hair  brush  previ- 
ously dipped  in  persulphate  of  iron  solution,  and  then  to 
irrigate  once  more  in  order  to  be  sure  that  the  haemorrhage 
is  checked.  The  patient  should  be  kept  quiet  in  bed,  cold 
external  applications  continued  several  hours,  and  other 
suitable  means  taken  to  prevent  erections,  but  the  parts 
should  not  be  meddled  with  any  further,  for  the  more 
handling,  the  greater  the  liability  to  recurrence  of  the 
haemorrhage.  Internal  pressure  by  the  introduction  and 
maintenance  in  position  of  a  large  catheter  has  been  recom- 
mended in  these  cases,  but  this  should  be  avoided  except  in 
the  most  extreme  circumstances.  The  presence  of  such  a 
foreign  body  becomes  almost  intolerable,  and  in  the  course 
of  three  or  four  days  is  liable  to  cause  ulceration  of  the 
mucous  membrane,  and  even  perforation  of  the  urethra  and 
urinary  fistula. 

Virulent  conjunctivitis  arises  from  the  accidental  con- 
tact of  pus  from  virulent  urethritis  with  the  conjunctiva. 
The  pus  may  be  conveyed  to  the  eye  by  a  soiled  hand  or 
through  some  other  medium,  such  as  a  towel  or  cloth  pol- 
luted with  urethral  pus.  The  right  eye  is  oftener  affected 
than  the  left,  and  both  eyes  are  very  rarely  involved.  This 
phlegmasia,  commonly  called  "  gonorrhoeal  ophthalmia,"  is, 
fortunately,  an  extremely  rare  accident  of  urethritis,  for  it 
is  ordinarily  superacute.  Though  it  may  resolve  in  a  few 
days  under  suitable  treatment,  leaving  but  slight  traces  of 


241 


its  occurrence,  its  sequelae  are  frequently  refractory  to 
treatment,  and  sometimes  fatal  to  vision.  Its  progress  is 
occasionally  so  rapid  that  the  eye  perishes  in  a  fev/  hours 
after  the  first  symptoms.  It  is  characterized  at  its  outset  by 
some  itching  of  the  edges  of  the  lids,  by  a  sensation  as  if  a 
small  foreign  body  had  lodged  beneath  the  eyelid,  and  by 
great  increase  of  lacrymation.  Then  follow  much,  turges- 
cence  of  the  conjunctival  capillaries,  chemosis,  intense  pain 
in  and  around  the  eye,  annoying  photophobia,  and  a  pro- 
fuse flow  of  pus.  The  chemosis  sometimes  increases  so 
rapidly  as  to  strangulate  and  destroy  the  cornea  before 
medical  aid  can  be  obtained. 

The  main  features  of  the  treatment  employed  by  expe- 
rienced ophthalmic  surgeons  is  here  given  to  guide  the  gen- 
eral physician  in  wbose  practice  cases  of  virulent  conjuncti- 
vitis occur,  for  the  salvation  of  these  inflamed  eyes  depends 
upon  the  promptness  and  efiiciency  of  the  treatment  which 
should  be  forthwith  begun,  to  be  vigorously  continued  until 
the  arrival  of  an  expert  ophthalmologist,  with  whom  the  re- 
sponsibility of  the  further  management  of  the  case  is  shared. 
But,  inasmuch  as  an  ophthalmologist  may  not  be  accessi- 
ble for  several  hours,  or  even  for  a  day,  as  in  small  towns, 
the  general  physician  should  render  himself  competent  to 
manage  cases  of  virulent  conjunctivitis  to  the  end.  For  his 
own  protection  he  should,  at  his  first  visit,  make  a  note  of 
the  exact  condition  of  the  eye,  and  have  some  person  to 
witness  this  examination  of  the  eye  and  of  the  writing  of 
the  memorandum,  which  he  should  sign  and  the  witness 

should  countersign. 
16 


242 


The  treatment  of  this  violent  phlegmasia  should  be 
most  prompt  and  energetic,  the  prime  indication  being  to 
check  the  rapid  phlegmasic  process  and  thwart  its  destruct- 
ive tendency.  In  the  early  stage,  and  then  only,  free  local 
depletion  should  be  effected  through  leeches  applied  to  the 
temple  close  to  the  outer  canthus  of  the  eye.  The  instilla- 
tion of  atropine  solution  should  at  once  be  begun,  to  be 
continued  to  the  end  of  the  phlegmasic  process.  Copious 
catharsis  should  be  induced.  The  patient  should  be  placed 
in  a  dark  room  and  his  sound  eye  properly  protected,  but 
the  inflamed  eye  should  not  be  covered.  A  nitrate-of-sil- 
ver  solution,  sixty  grains  to  the  ounce,  should  be  applied 
once  each  day  to  the  whole  conjunctival  surface  with  a 
camel's-hair  brush,  and  immediately  washed  away.  When 
chemosis  appears,  free  cuts  should  be  made  through  the 
conjunctiva  radiating  from  the  cornea's  edge.  But  what  is 
most  efficient  and  most  to  be  depended  upon  to  relieve  the 
chemotic  pressure  upon  the  eye  is  free  section  of  the  ex- 
ternal canthus,  including  the  dense  aponeurotic  layer,  and 
this  simple  operation  can  not  too  soon  be  employed  in  cases 
of  extreme  chemosis.  Almost  incessant  ablutions  of  the 
eye  during  the  first  forty-eight  hours  should  be  made  with 
cold,  mildly  astringeni,  antiseptic  solutions,  and  this  eye 
kept  under  the  watchful  care  of  a  trustworthy  and  faithful 
nurse,  who  shall  obey  strictly  the  physician's  directions. 
After  forty- eight  hours,  or  after  the  danger  of  strangula- 
tion of  the  cornea  is  passed,  the  ablutions  need  not  be  so 
frequent  and  the  nitrate-of-silver  solution  may  be  weaker, 
but  still  used  once  daily  until  the  conjunctival  membrane 


243 


appears  normal.  If  the  whole  cornea  have  already  sloughed, 
the  eyeball  should  be  extirpated  as  soon  as  expedient  after 
the  termination  of  the  phlegmasic  process. 

Complications  of  Urethritis. — Balanitis — phlegmasia 
of  the  glans  penis,  involving  the  mucous  membrane,  the 
spongy  substance,  or  both — is  characterized,  in  the  first  case, 
by  an  itchy  and  burning  sensation,  more  or  less  intense  red- 
ness, swelling,  and  at  length  a  purulent  discharge.  It  may 
be  of  the  same  nature  as,  or  may  have  appeared  before,  the 
urethritis,  by  which  it  is  intensified,  particularly  when  caused 
by  the  accumulation  of  smegma.  In  superacute  urethritis 
there  sometimes  occurs  an  abundant  plastic  exudation  in 
the  substance  of  the  glans  penis,  which  swells  and  becomes 
very  tense.  Eesolution  is  slow  or  is  not  accomplished,  and 
the  imperfectly  organized  exudate  undergoes  sclerous  de- 
generation, causing  irregular  shriveling  of  the  glans.  Sub- 
acute balanitis,  with  plastic  exudation  and  induration  of  the 
glans,  is  often  the  outcome  of  violent,  careless,  and  unduly 
frequent  catheterism.  The  induration  thus  caused  is  most 
apparent  around  the  urinary  meatus,  and  is  in  some  cases 
so  strongly  marked  as  to  be  mistaken,  at  first  sight,  for  ma- 
lignant disease. 

Posthitis — phlegmasia  of  the  foreskin  of  the  penis,  aSect- 
ing  its  mucous  layer,  its  cutaneous  layer,  or  both  of  these 
layers — sometimes  exists  independently  of  balanitis,  but,  as 
a  general  rule,  is  associated  with  balanitis  and  is  designated 
as  balano-posthitis.  Posthitis  occurs  frequently  in  young 
subjects  afEected  with  vesical  stone,  causing  frequent  and 


244 


painful  urination  and  subacute  urethritis ;  this  frequent 
escape  of  urine,  and  the  traction  upon  the  prepuce  made 
by  the  sufferers  in  endeavoring  to  obtain  relief,  being  the 
exciting  cause  of  the  posthitis.  The  foreskin  is  elongated, 
sodden,  swollen,  red,  and  painful,  and  its  mucous  membrane 
emits  pus  and  sometimes  blood.  This  sodden  condition  of 
a  long  prepuce  in  the  adult  occurs  in  cases  of  urethral  steno- 
sis and  obstruction  to  urination  from  other  causes  leading 
to  unduly  frequent  urination  or  to  constant  dribbling  of 
urine. 

Infibulation  of  the  prepuce — a  device  of  very  ancient 
date,  to  insure  continency  among  the  young  until  the  age 
of  twenty-five,  described  by  Celsus,  practiced  extensively  in 
the  middle  ages,  condemned  by  Dionis  and  others  during 
the  seventeenth  century,  seriously  recommended  within  the 
last  fifteen  years  as  a  cure  for  "  epilepsy  and  seminal  loss  " — 
is  still  occasionally,  but  secretly,  employed.  It  is  hurtful 
not  only  on  account  of  its  favoring  the  accumulation  of 
filth,  but  of  the  irritation  excited  by  the  buckle,  which  is 
liable  to  induce  posthitis  with  so  much  induration  of  the 
foreskin  as  to  lead  to  the  suspicion  of  malignant  disease. 
Dupuytren  relates  such  a  case  which  at  first  he  believed  to 
be  cancer  of  the  prepuce.  The  jealous  mistress  of  the  pa- 
tient had  succeeded  in  inserting  an  ingeniously  contrived 
gold  ring  through  the  end  of  the  foreskin  and  had  locked 
it.  In  the  course  of  time  the  extremity  of  the  penis  was  so 
much  enlarged,  indurated,  and  painful,  that  the  ring 
was  removed ;  this  afforded  relief  from  the  pain,  but  the 
swelling  and  induration  were  slow  in   yielding   to   treat- 


245 


ment.  The  parts  finally  regained  in  a  measure  their  normal 
state. 

Balano-posthitis  is  generally  due  to  the  accumulation  of 
smegma  beneath  a  long  prepuce,  but  at  times  it  begins  with 
the  attack  of  urethritis,  and  is  even  superacute  and  asso- 
ciated with  lymphangeiitis.  The  mucous  membranes  of  the 
glans  and  prepuce  are  tumid,  of  a  vivid  red,  very  sensitive, 
and  emit  a  considerable  quantity  of  pus.  In  extreme  cases, 
complicated  with  phimosis,  these  mucous  membranes  ulcer- 
ate in  patches,  so  that  when  cicatrization  is  accomplished 
the  two  surfaces  adhere  permanently  unless  precautions  are 
taken  against  the  occurrence  of  such  adhesion. 

The  treatment  of  balanitis  and  balano-posthitis,  in  cases 
where  only  the  mucous  membranes  are  involved,  and  the 
prepuce  is  short  or  easily  retracted,  consists  in  thoroughly 
cleansing  the  glans  and  prepuce  with  antiseptic  solutions 
three  or  four  times  daily,  and  after  each  washing  to  cover 
the  affected  parts  with  a  thin  layer  of  a  powder  composed 
of  equal  parts  of  oxide  of  zinc  and  boric  acid,  or  else 
aristol,  or  europhen  which  is  said  to  be  an  iodide  of  iso- 
butylorthocresol  and  which  does  not  possess  the  objection- 
able odor  of  iodoform.  Ointments  are  not  tolerated  in  the 
majority  of  cases. 

Phimosis. — Balano-posthitis  complicated  with  phimosis 
not  being  amenable  to  treatment  by  powders,  the  preputial 
cavity  should  be  irrigated  with  antiseptic  fluids  two  oi 
three  times  daily  until  the  subsidence  of  the  phlegmasic 
process.  If  the  prepuce  be  only  long  enough  to  cover  the 
glans  penis,  divulsion  of  the  preputial  orifice  may  be  em- 


246 

ployed  to  relieve  tlie  eonstriction ;  but  if  this  orifice  be  ex- 
tremely narrow  or  its  edges  mucli  indurated,  postbetomy 
will  be  the  more  efficient  procedure.  Tbis  operation  con- 
sists in  making  a  longitudinal  incision  tbrougb  tbe  skin  and 
mucous  membrane  of  tbe  prepuce  on  its  dorsal  aspect,  so  tbat 
tbe  glans  can  be  easily  exposed.  The  edges  of  tbe  skin  and 
mucous  membrane  should  then  be  stitched  together,  so  as  to 
obtain  a  transverse  scar  from  the  longitudinal  incision,  and 
thus  increase  the  size  of  the  preputial  opening. 

When  the  prepuce  is  long  and  so  narrow  as  to  render 
its  retraction  difficult  or  impracticable,  posthectomy  should 
be  performed,  but  not  until  the  subsidence  of  the  phleg- 
masic  process,  unless  the  integrity  of  the  glans  be  imperiled 
by  the  existence  of  chancroids.  This  minor  operation,  per- 
formed for  many  thousand  years  largely  as  a  religious  rite, 
consists  in  cutting  away  tbe  superabundant  foreskin  and 
enough  of  its  mucous  membrane  to  permit  the  glans  penis 
to  be  easily  uncovered.  As  a  religious  rite  the  greater  part, 
if  not  the  whole  prepuce,  is  removed.  For  tbe  purposes  of 
the  surgeon  it  is  rarely  necessary  to  make  a  complete 
posthectomy.  The  operation  is  the  same  in  principle  as  it 
has  ever  been,  but  its  details  have  undergone  many  hun- 
dreds of  modifications.  Tbe  essential  steps  of  posthectomy 
are — 1,  to  pull  gently  forward  the  prepuce ;  2,  to  apply  a 
suitable  clamp  to  retain  it  in  position  and  to  protect  from 
injury  the  extremity  of  the  glans  penis ;  3,  to  quickly  cut 
away  all  that  part  of  the  prepuce  isolated  by  the  clamp  ;  4, 
to  remove  the  clamp  and  slit  the  mucous  membrane  longi- 
tudinally not  more  than  half  an  inch ;   5,  to  trim  with  scis- 


247 

sors  the  angles  of  the  mucous  membrane ;  6,  to  take  proper 
means  to  arrest  any  oozing  of  blood  or,  if  necessary,  to  tie 
bleeding  vessels  ;  7,  to  stitch  the  mucous  membrane  to  the 
skin  with  very  fine  silk  or  with  horse-hair ;  and  8,  to  apply 
a  light  dressing  to  the  parts.  In  very  young  subjects  no 
stitching  is  necessary.  Ordinarily  the  wound  heals  pri- 
marily. 

Paraphimosis,  an  accident  of  phimosis,  occurs  from  the 
forcible  retraction  of  a  narrow  prepuce  for  the  purpose  of 
cleansing  the  glans,  or  during  coition  or  masturbation.  It 
is  then  very  difficult  or  impossible  for  the  patient  to  bring 
foward  the  retracted  prepuce,  owing  to  swelling  of  the  glans 
penis.  When  paraphimosis  has  existed  several  days  it  is 
not  possible  sometimes,  even  after  section  of  the  constrict- 
'ing  ring,  to  replace  the  foreskin.  Ordinarily  it  is  rather  an 
inconvenient  and  unsightly  deformity  than  a  dangerous  con- 
dition, for  the  glans  penis  is  very  rarely  damaged  by  an  irre- 
ducible paraphimosis.  A  portion  of  the  dense  ring  into 
which  the  retracted  prepuce  is  converted  finally  sloughs  and 
the  strangulation  ceases,  but  the  adhesions  which  take  place 
forbid  the  ultimate  reduction  of  the  prepuce. 

The  reduction  of  the  retracted  prepuce  in  paraphimosis 
can  generally  be  eif  ected  by  compressing  the  glans  penis  and 
pushing  it  backward  while  the  prepuce  is,  as  it  were,  un- 
rolled upon  the  glans,  using  for  this  purpose  the  thumb  and 
index  and  middle  fingers  of  each  hand.  This  process  is  ap- 
plicable only  before  the  glans  penis  has  become  very  tumid. 
When  the  tumefaction  of  the  glans  is  such  as  to  forbid  re- 
duction by  this  method,  a  simple  and  quick  process  is  to 


248 

apply  elastic  compression  by  means  of  a  bandage,  one  incb 
wide,  of  tbin  India-rubber,  such  as  dental  surgeons  use  un- 
der the  name  of  rubber  dam.  Compression  so  made  expels 
the  blood  from  the  glans  and  sufficiently  decreases  its  size  to 
permit  of  reduction  of  the  retracted  prepuce.  The  last  turns 
of  the  bandage  should  be  applied  to  the  oedematous  prepuce 
to  expel  the  serum  from  the  meshes  of  its  connective  tissue. 
The  bandage  is  not  removed  from  the  glans  penis  until  the 
reduction  is  nearly  complete.  It  has  been  proposed  to  re- 
lieve paraphimosis  by  placing  the  patient  on  his  back,  grasp- 
ing the  penis  with  one  hand,  and  striving  thus  to  lift  him. 
This  is  said  to  have  been  practiced  on  children  as  well  as  on 
adults.  The  violence  of  this  remedy  is  such  as  to  make  it 
worse  than  the  discomfort  which  it  is  designed  to  relieve, 
for  the  traction  incident  to  the  effort  of  raising  the  whole 
body  by  the  penis  is  so  great  as  to  seriously  injure  the  ure- 
thra, and  possibly  also  the  cavernous  bodies. 

Consequences  of  Urethritis. — LympJiangeiitis  of  the 
larger  subcutaneous  lymphatic  vessels  of  the  penis  occurs  in 
consequence  of  slight  injuries,  of  friction  by  the  clothing 
during  exercise,  or  of  the  untimely  use  of  urethral  injec- 
tions. The  phlegmasia  may  be  subacute,  acute,  or  super- 
acute. 

Subacute  lymphangeiitis  is  characterized  by  its  indolence, 
by  the  slight  engorgement  of  the  subcutaneous  lymphatics, 
and  by  a  little  oedema  of  the  neighboring  connective  tissue. 
It  is  a  frequent  consequence  of  acute  urethritis  and  may  ap- 
pear during  the  first  ten  days  or  not  until  the  decline  of  the 


249 

pMegmasia.  It  rarely  suppurates  and  resolves  under  rest 
and  simple  lotions  in  the  course  of  four  weeks. 

Acute  lymphangeiitis  is  characterized  by  longitudinal 
reddish  tracts  in  the  course  of  the  lymphatics,  which  are 
tense,  nodulated,  and  tender  to  the  touch,  from  the  preputial 
frajnum  to  the  inferior  inguinal  glands  where  they  terminate. 
The  prepuce  is  much  swollen  from  serous  exudation,  and 
sometimes  the  whole  phallic  integument  is  in  the  same  tumid 
condition.  This  type  of  lymphangeiitis  very  rarely  suppu- 
rates, and  resolves  in  the  course  of  three  or  four  weeks  un- 
der absolute  rest  in  recumbency  and  soothing  lotions. 

Superacute  lymphangeiitis  is  characterized  by  a  diffuse 
erysipelatous  redness  and  swelling  of  the  integument  of  the 
whole  penis.  Although  it  most  frequently  resolves  under 
the  same  management  as  the  acute  type,  it  is  sometimes  fol- 
lowed by  abscesses  in  the  course  of  the  lymphatics,  and  in 
very  rare  instances  by  diffuse  suppuration,  requiring  free 
and  early  incision.  In  still  more  rare  instances  the  phleg- 
masia is  propagated  to  the  cavernous  bodies  of  the  penis 
(phalli tis),  and  leaves  a  certain  amount  of  induration  which 
deforms  the  penis  during  erection.  This  plastic  exudation 
in  the  cavernous  bodies  sometimes  undergoes  calcareous  in- 
filtration, a  condition  often  miscalled  bony  transformation 
of  the  penis. 

Inguinal  adenitis  often  follows  lymphangeiitis  of  the 
penis  consequent  upon  urethritis,  but  it  also  occurs  without 
there  being  any  lymphangeiitis,  and  may  appear  as  a  conse- 
quence of  any  of  the  forms  of  virulent  urethritis  or  of  simple 
non-contagious  urethritis.    One  or  more  than  one  gland  may 


250 

be  inflamed.  The  pMegmasia  may  resolve  after  a  few  days 
of  rest,  may  be  indolent,  or  suppuration  may  ensue.  This 
form  of  adenitis  is  one  of  the  varieties  of  non-syphilitic  bu- 
boes ;  there  being  two  varieties,  one  of  which  resulting  from 
chancroids  of  the  penis  or  urethi'a,  the  other  from  non-in- 
fecting urethritis.  These  buboes  are  ordinarily  on  a  level 
with  or  a  little  below  Poupart's  ligament,  and  may  be  uni- 
lateral or  bilateral.  In  the  event  of  suppuration,  the  dis- 
eased glands  should  be  freely  incised,  and  in  some  cases 
excised. 

Peri-urethritis  arises  as  a  consequence  of  acute,  but 
more  frequently  of  superacute,  urethritis,  the  phlegmasic 
process  extending  itself  to  the  submucous  connective  tissue 
or  even  to  the  spongy  substance,  and  occupying  a  part  or 
the  whole  circumference  of  the  urethral  canal.  It  occurs  in 
the  perineal,  in  the  scrotal,  or  in  the  phallic  region  of  the 
urethra,  most  frequently  in  the  last-named  region.  It  is 
often  provoked  by  untimely  urethral  injections,  by  the  so- 
called  abortive  treatment  of  benign  urethritis  with  strong 
solutions  of  nitrate  of  silver,  by  violence  to  the  inflamed 
urethra  such  as  may  occur  from  coition  or  from  masturba- 
tion, or  by  any  ingested  substance  which  may  render  the 
urine  acrid.  It  is  characterized  by  a  more  or  less  abundant 
plastic  exudation  in  the  submucous  connective  tissue,  or 
both  this  and  the  spongy  substance.  The  exudation  may 
occupy  the  whole  extent  of  the  inflamed  part  of  the  urethra 
or  may  be  confined  to  one  or  several  isolated  points,  caus- 
ing much  pain  during  erection  and,  to  a  greater  or  less  ex- 
tent, curvation  of  the  penis  (chordee).     When  the  exudate 


251 

retains  its  semi-fluidity  it  may  soon  be  absorbed,  or  may 
end  in  suppuration  and  peri-urethral  abscess.  The  abscess 
opens  oftener  in  the  urethra  than  externally.  In  the  latter 
case  the  urethra  may  be  perforated  and  a  urinary  fistula 
thus  established.  When  the  exudate  is  partly  organized, 
sclerous  degeneration  begins  and  urethral  stenosis  is  the 
sequel.  This  sclerous  degeneration  may  be  so  rapid  that 
in  a  few  months  the  lumen  of  the  urethra  is  reduced  to  the 
point  of  admitting  only  a  capillary  bougie,  or  it  may  be  so 
slow  that  five,  ten,  twenty,  or  even  thirty  years  may  elapse 
before  the  caliber  of  the  urethra  is  sufficiently  reduced  to 
attract  the  attention  of  the  sufferer. 

In  the  treatment  of  peri-urethritis  the  first  indication  is 
the  discontinuance  of  the  injections  which  may  have  pro- 
voked the  phlegmasia.  If  balsamics  had  already  been  ad- 
ministered, they  too  should  be  discontinued.  The  patient 
should  be  confined  to  bed  for  five  or  six  days,  and  means 
taken  to  abate  the  frequent  and  painful  erections  of  the 
penis  which  so  much  aggravate  the  phlegmasic  process.  An 
evaporating  lotion,  or,  better,  dry  cold,  by  mediate  irriga- 
tion, as  suggested  by  Petitgand,  applied  through  India- 
rubber  tubing  of  small  size  and  thin  walls,  coiled  around 
the  penis  so  that  a  continuous  flow  of  water  at  any  desir- 
able temperature  may  be  used  without  wetting  the  bed  or 
otherwise  inconveniencing  the  patient,  has  the  double  efEect 
of  preventing  erections  and  of  acting  as  a  local  antiphlo- 
gistic. The  urine  should  be  rendered  bland  by  the  admin- 
istration of  diluent  drinks,  and  flve  grains  of  gum  camphor, 
one  grain  of  hyoscyamus  extract,  and  five  grains  of  taraxa- 


252 


cum  extract,  made  into  a  bolus,  should  be  taken  at  bed-time 
and,  if  necessary,  once  again  during  tbe  nigbt. 

When  these  means  fail  to  induce  resolution,  and  sup- 
puration ensues,  the  peri-urethral  abscess  opening  in  the 
urethral  canal,  it  is  necessary  to  take  measures  to  prevent 
the  entrance  of  urine,  rare  as  this  occurrence  may  be,  into 
the  abscess  cavity  for  two  or  three  days,  or  until  the  forma- 
tion of  granulation  tissue.  This  is  effected  by  the  passage  of 
a  small,  soft  catheter  whenever  urination  becomes  necessary. 
If  the  abscess  points  externally,  it  may  be  incised,  or,  if  small, 
the  few  drops  of  pus  it  contains  may  be  removed  by  aspira- 
tion, as  advised  by  Christian  Smith.  For  this  purpose  the  or- 
dinary syringe  employed  for  hypodermic  injections  may  be 
used.  This  simple  process,  perhaps  repeated  two  or  three 
times,  tends  to  prevent  urinary  fistula.  Should  it,  however, 
fail,  a  sufficiently  free  external  incision  would  be  indicated. 

When  resolution  is  slow  or  when  the  exudate,  instead 
of  leading  to  suppuration,  becomes  more  consistent,  with  a 
tendency  to  undergo  organization,  the  oleate  of  mercury, 
applied  daily  along  the  under  surface  of  the  penis  or  the 
perinseum,  according  to  the  site  of  the  peri-urethritis,  is  of 
much  advantage.  In  obstinate  cases  the  oleate  of  mercury 
may  be  replaced  by  vesicating  coUodium  once  every  week 
until  this  vesication  has  been  used  three  or  four  times.  In- 
ternally the  bromides  of  sodium,  ammonium,  and  potas- 
sium, two  grains  each,  should  be  given  in  a  wineglass  of 
water  four  times  a  day  for  a  week  or  ten  days. 

Resolution  failing,  the  peri-urethritis  becoming  chronic, 
or  sclerotic  degeneration  beginning,  which   is  the  same  as 


253 


saying  tliat  a  stenotic  process  is  established,  the  most  effi- 
cient method  of  treatment,  designed  to  prevent  the  forma- 
tion of  a  narrow  stricture,  is  free  dilatation  of  the  urethra 
once  a  week  continued  several  months. 

Urethral  cryptitis — phlegmasia  of  the  mucous  follicles 
of  the  urethra — a  common  consequence  of  acute  urethritis, 
is  often  very  persistent  and  sometimes  constitutes  the  main 
cause  of  chronic  urethral  discharges.  It  occurs  most  fre- 
quently in  the  balanic  region,  but  may  affect  one  or  many 
follicles  in  any  part  of  the  urethral  canal.  It  happens  occa- 
sionally in  acute  urethral  phlegmasia  that  the  mouth  of  a 
follicle  becomes  occluded  by  swelling  of  the  mucous  mem- 
brane. Purulent  accumulation  ensues,  distends  the  follicle, 
and  forms  a  small,  hard,  globular,  or  ovoid  abscess,  contain- 
ing only  four  or  five  drops  of  pus,  which  is  finally  dis- 
charged into  the  urethra,  or  externally  through  a  very  narrow 
orifice.  This  orifice  does  not  always  close,  and  there  re- 
mains a  fistulous  tract  through  which  some  urine  escapes. 
To  prevent  the  formation  of  a  fistula,  an  attempt  should  be 
made  to  open  the  mouth  of  the  inflamed  follicle  with  a  slen- 
der probe,  such  as  the  smallest  used  in  stenosis  of  the 
lacrymai  ducts,  so  that  the  pus  may  escape  in  the  urethra. 
This  failing,  aspiration  is  made  as  in  peri-urethral  abscess,  or 
even  external  incision.  The  treatment  of  chronic  cryptitis 
will  be  considered  under  the  head  of  chronic  urethritis. 

Bulho-urethral  adenitis  is  a  rare  consequence  of  acute 
.urethritis.  This  phlegmasia  having  already  been  described, 
it  is  now  only  necessary  to  thus  briefly  notice  it  as  a  conse- 
quence of  acute  urethritis. 


254 


Prostatitis,  having  also  been  described,  requires  no  fur- 
ther examination. 

Orchitis  is  used  as  a  generic  term  to  signify  a  phleg- 
masia affecting  any  or  all  of  the  divisions  of  the  testicle. 
Epididymitis  is  the  term  commonly  used  for  phlegmasia  of 
the  summit  of  the  testicle,  and  didymitis  for  phlegmasia  of 
the  body  of  the  testicle,  the  latter  occurring  rarely.  Of 
222  cases  of  epididymitis  consequent  upon  urethritis  ob- 
served by  Fournier,  164  were  from  acute  urethritis  and  58 
from  chronic  urethritis.  Of  the  164  cases  from  acute  ure- 
thritis, 6  occurred  during  the  first  ten  days  of  the  urethri- 
tis, 15  on  the  eleventh  day,  34  during  the  third  week,  30 
during  the  fourth  week,  29  during  the  fifth  week,  19  dur- 
ing the  sixth  week,  9  during  the  seventh  week,  and  21  dur- 
ing the  eighth  week.  Of  the  58  cases  from  chronic  ure- 
thritis, 22  occurred  during  the  third  month,  1  during  the 
seventh  year,  and  the  remainder  scattered  between  the  fifth 
month  and  the  fourth  year. 

Epididymitis  is  a  frequent  consequence  of  urethritis. 
It  occurs  in  about  thirty  per  cent,  of  all  cases  of  acute  ure- 
thritis, and  generally  appears  on  or  about  the  third  week 
from  the  beginning  of  the  urethritis — ^.  e.,  during  its  period 
of  decline,  or  after  it  has  reached  the  prostatic  region. 
However,  this  extension  of  the  phlegmasia  to  the  prostatic 
region  sometimes  occurs  in  a  few  days  after  the  beginning 
of  the  urethritis,  particularly  if  the  urethritis  begins  in  the 
prostatic  region.  In  either  case,  epididymitis  may  begin 
very  soon  after  the  development  of  urethritis.  It  arises 
from  extension  of  the  phlegmasic  action,  by  continuity  of 


255 


mucous  membrane  and  lymph- vessels,  tlirougli  the  ejacula- 
tory  duct  and  spermatic  canal,  and  thus  reaches  the  epi- 
didymis. In  some  cases  the  phlegmasic  action  is  most 
intense  in  the  spermatic  canal,  and  is  even  propagated  by 
the  lymph-vessels  to  the  spermatic  cord.  In  these  cases 
there  is  sometimes  little  swelling  or  pain  in  the  epididymis, 
while  at  other  times  the  epididymis  is  much  swollen,  very 
painful,  and  accompanied  by  perididymitis,  the  pain  ex- 
tending to  the  inguinal  region  and  even  to  the  abdomen. 
These  last  are  cases  of  superacute  epididymitis. 

A  young  man  affected  with  superacute  epididymitis 
complained,  on  or  about  the  third  day,  of  severe  pain,  ex- 
tending from  the  testicle  and  spermatic  cord  to  his  abdo- 
men, which  soon  became  distended.  This  was  the  begin- 
ning of  a  sharp  seizure  of  peritonitis,  from  which  he,  how- 
ever, recovered.  A  little  reflection  as  to  the  explanation 
of  the  attack  of  peritonitis  led  to  the  conclusion  that  the 
canal  between  the  peritoneal  cavity  and  the  tunica  vagina- 
lis, formed  in  foetal  life  by  the  descent  of  the  testicle,  had 
remained  patent,  and  that  the  phlegmasia  of  the  tunica  vagi- 
nalis, consequent  upon  the  epididymitis,  had  through  this 
channel  extended  itself  to  the  peritonaeum.  It  is  worth 
while  to  take  into  account  the  possible  existence  of  such  an 
anomaly  in  case  of  peritonitis  arising  in  connection  with 
epididymitis,  though  it  is  also  possible  for  peritonitis  to 
occur  by  transmission  through  the  medium  of  lymph- ves- 
sels. 

Phlegmasia  of  the  epididymis  may  be  developed  slowly 
and  gradually  in  six  or  eight  days,  or  may  be  superacute 


256 


and  reach  its  heigM  in  twenty-four  liours.  It  is  often  at- 
tended with  febrile  reaction  and  gastic  disturbance — furred 
tongue,  nausea,  vomiting,  etc.  Ordinarily,  however,  it  at- 
tains its  maximum  of  intensity  in  the  course  of  three  or 
four  days.  Both  testicles  rarely  suffer  at  the  same  time. 
The  phlegmasic  action  may  affect  only  that  part  known  as 
the  tail  of  the  epididymis,  may  be  extended  to  the  body,  or 
may  be  most  intense  in  the  head  of  the  epididymis.  This 
same  phlegmasic  process  frequently  involves  one  or  both 
seminal  vesicles.  Suppuration  is  a  very  uncommon  result 
of  epididymitis.  Resolution  occurs  on  or  about  the  third 
week ;  but  there  often  remains  some  induration  at  one  or 
two  points  at  the  head  or  toward  the  tail,  or  the  whole  of 
the  epididymis  becomes  sclerosed,  and  finally  shrivels. 
Epididymitis  occasionally  recurs  several  times  in  the  course 
of  three  or  four  months  on  the  same  side,  and  sometimes 
on  the  opposite  side — orchite  a  bascule  (Ricord).  These 
recurrences  are  apt  to  be  owing  to  the  existence  of  small 
abscesses  in  the  substance  of  the  epididymis. 

One  of  the  occasional  consequences  of  bilateral  epididy- 
mitis is  sterility.  This  is  owing  to  chronic  phlegmasia  of 
both  spermatic  canals,  the  acid  pus  destroying  the  sperma- 
tozoa. In  some  cases  these  canals  become  completely  oc- 
cluded by  a  gradual  stenotic  process,  with  destruction  of 
the  epithelium,  or  by  pressure  from  without  at  the  tail  of 
the  epididymis  during  the  shriveling  of  a  phlegmasic 
nodule. 

Several  patients  who  had  suffered  bilateral  epididy- 
mitis married  healthy  women,  whom  they  have  never  sue- 


257 


ceeded  in  impregnating.  One  of  them  married  a  second 
time,  and  Ms  wife,  a  well-formed  woman  in  excellent  physi- 
cal condition,  had  not  become  pregnant  ten  years  after. 

Didymitis  and  epididymitis  are  specialized  because,  in 
the  first  case,  the  phlegmasia  sometimes  scarcely  affects  the 
epididymis,  but  expends  itself  on  the  body  of  the  testicle, 
and,  in  the  second  case,  because  often  the  spermatic  canal 
is  very  little  affected,  and  the  body  of  the  testicle  is  intact, 
while  the  epididymis  is  the  center  of  the  phlegmasic  pro- 
cess. To  warrant  this  specialization  there  are  other  reasons, 
among  which  may  be  mentioned  that  didymitis  sometimes 
arises  from  direct  violence  to  the  body  of  the  testicle,  and 
that  this  didymitis  is  said  to  occur  secondarily  to  parotitis 
and  to  variola  without  epididymitis. 

Didymitis,  consecutive  to  epididymitis,  may  be  subacute, 
acute,  or  superacute.  It  may  resolve  in  three  or  four 
weeks,  may  suppurate,  may  end  in  gangrene  of  the  testicle 
in  two  or  three  days,  or  become  chronic.  Superacute  epi- 
didymitis is  almost  always  attended  with  perididymitis,  and 
sometimes  with  parenchymatous  didymitis.  In  either  case 
there  is  true  orchitis,  all  the  divisions  of  the  testicle  being 
affected. 

Subacute  parenchymatous  didymitis  is  attended  with 
little  pain,  but  is  slow  in  resolving,  and  liable  to  recur  every 
few  weeks.  These  recurrences  forebode  the  development 
of  purulent  foci  in  the  testicle.  After  three  or  four  recur- 
rences of  dull  pain  and  a  sense  of  tension  in  the  testicle,  the 
two  layers  of  the  tunica  vaginalis  become  adherent  ante- 
riorly or  laterally.  This  is  evidence  that  an  abscess  is  ap- 
17 


258 


proachmg  tlie  surface.  It  happens  that  in  some  cases  a 
single  abscess  is  formed,  becomes  encysted,  and  is  not 
recognized  until  the  diseased  testicle  is  removed  and  cut 
open,  when  a  central  mass  of  cheesy  pus  is  enucleated. 

Acute  parenchimatous  didymitis,  though  very  painful, 
the  pain  extending  from  the  testicle  along  the  spermatic 
cord  to  the  inguinal  and  even  to  the  lumbar  region,  gener- 
ally resolves  with  the  accompanying  epididymitis,  and  very 
rarely  suppurates.  Sometimes  resolution  fails  and  the 
phlegmasia  becomes  chronic.  The  seminiferous  tubules  are 
then  plugged  with  plasma,  and  the  intertubular  substance 
is  soon  involved,  sclerosis  and  shriveling  of  the  testicle  en- 
suing. This  is  not  an  uncommon  occurrence  in  cases  of 
didymitis  consecutive  to  parotitis.  There  is  a  type  of  didy- 
mitis in  which  the  testicle  remains  indurated  for  many 
months,  and  finally  breaks,  by  ulceration,  through  the 
bounds  of  its  tunics  and  integument,  and  is  extruded  as  a 
fungoid  mass,  named  benign  fungus,  sometimes  mistaken 
for  syphilitic  or  for  tubercular  disease.  Benign  fungus  oc- 
curs among  persons  whose  health  is  much  deteriorated  by 
debauchery  and  its  consequences.  This  so-called  benign 
fungus  consists  of  no  other  elements  than  those  composing 
the  testicle  in  a  state  of  chronic  phlegmasia,  together  with  a 
covering  of  granulation  tissue. 

Superacute  didymitis  is  of  rare  occurrence.  It  is  at- 
tended with  very  great  pain  and  much  febrile  reaction, 
reaching  its  maximum  of  intensity  within  forty -eight  hours, 
when  the  fate  of  the  testicle  is  decided,  for  after  this  the 
phlegmasic  process  is  on  the  decline  or  the  testicle  is  in 


259 


a  gangrenous  state.  The  whole  body  of  the  testicle  is  af- 
fected, the  intertubular  as  well  as  the  tubular  substance. 
Its  form  and  size  are  unchanged,  the  fibrous  tunic  yield- 
ing no  space  for  swelling,  hence  the  occurrence  of  gan- 
grene, the  hardness,  and  the  almost  intolerable  sense  of 
tension  experienced  by  the  sufferer.  Even  when  the  tes- 
ticle escapes  gangrene  it  is  likely  to  be  otherwise  injured, 
for  it  either  suppurates  or  ends  in  chronic  induration, 
sclerous  degeneration,  and  shriveling. 

The  treatment  of  epididymitis  should  be  adapted  to 
the  degree  of  the  phlegmasia  and  to  the  peculiarities  of  in- 
dividuals. Fretful,  hyperaesthetic,  algophobic  patients 
affected  with  the  mildest  epididymitis  are  sickened  by  what 
others  regard  as  a  minor  degree  of  pain,  and  require  to  be 
tranquillized  by  free  doses  of  the  bromides  or  even  of 
opium.  Otherwise  the  mild  cases  need  nothing  more  than 
rest  and  suspension  of  the  testicle.  Other  patients  affected 
with  superacute  phlegmasia,  endangering  the  testicle,  make 
little  or  no  complaint,  though  they  experience  much  pain. 
In  these  cases  prompt  antiphlogistic  treatment  and  the 
closest  attention  are  necessary  to  save  the  testicle. 

Acute  epididymitis  demands  free  catharsis,  rest  in  the 
horizontal  posture,  and  the  ice-bag  for  forty-eight  hours, 
or  perhaps  longer.  There  are  cases  in  which  cold  applica- 
tions fail  to  relieve  pain ;  in  these,  hot  fomentations  often 
have  the  desired  effect  in  the  course  of  a  few  hours.  The 
testicle  should  then  be  swathed  in  a  thick  layer  of  carded 
cotton  sprinkled  with  half  an  ounce  of  tincture  of  opium, 


260 


and  the  whole  well  suspended.  In  case  of  phlegmasia  of 
the  spermatic  cord  with  much  pain,  a  small  plaster  com- 
posed of  powdered  opium  (one  drachm)  and  a  sufficient 
quantity  of  water  to  make  a  thin  paste  should  be  applied 
over  the  inguinal  canal,  as  recommended  by  Velpeau,  after 
ten  or  twelve  leeches  have  extracted  as  many  ounces  of 
blood  from  that  region.  As  a  general  rule,  poultices  should 
not  be  used  ;  they  are  particularly  hurtful  in  cases  compli- 
cated with  scrotal  dermatitis.  When  there  occurs  effusion 
of  serum  in  the  tunica  vaginalis  (acute  hydrocele),  attended 
with  much  pain,  relief  is  very  soon  afforded  by  making  fif- 
teen or  twenty  punctures  with  an  exploring  needle,  the 
serum  escaping  in  the  scrotal  connective  tissue.  "  Strap- 
ping "  is  worse  than  useless  and  is  sometimes  destructive 
to  the  testicle.  The  patient  should  be  kept  in  the  hori- 
zontal posture  for  at  least  a  week,  and  the  testicle  properly 
supported  during  that  time  and  for  two  or  three  weeks 
thereafter.  When  suppuration  has  taken  place  in  any  part 
of  the  epididymis  free  incision  should  be  made  without 
delay. 

The  treatment  of  didymitis  is  essentially  the  same  as 
that  of  epididymitis,  except  in  the  case  of  the  superaciite 
type,  which  demands  more  heroic  antiphlogistic  measures, 
beginning  with  the  application  of  at  least  sixteen  leeches  in 
the  inguinal  region  on  the  affected  side.  Then  the  ice-bags 
— one  anteriorly,  the  other  posteriorly,  as  suggested  by  Curl- 
ing— should  be  used  continuously  night  and  day  for  four  or 
five  days.     Sufficiently  free  doses  of  opium,  or  of  morphine 


261 


hypodermically,  to  blunt  the  senses  and  induce  sleep,  are 
absolutely  necessary.  The  prime  indication  is  to  prevent 
the  occurrence  of  suppuration  or  of  gangrene  of  the  semi- 
niferous tubules.  When  the  violence  of  the  phlegmasia  is 
expended,  when  the  pain  is  relieved,  the  affection  is  to  be 
dealt  with  as  in  the  case  of  epididymitis.  But  when,  in  the 
course  of  thirty-six  or  forty-eight  hours,  the  faithful  use  of 
ice  and  of  the  other  antiphlogistic  agents  fails  to  subdue 
the  phlegmasic  process,  and  the  sense  of  tension  is  rapidly 
increasing,  a  free  incision  should  be  made  through  the 
scrotum  and  tunica  albuginea.  This  is  imperative  as  the 
only  means  of  increasing  the  space  for  swelling  or  of  re- 
establishing the  local  capillary  circulation  and  thus  prevent- 
ing necrosis  of  the  seminiferous  tubules.  The  patient  has 
a  right  to  the  benefit  of  the  doubt,  if  any  doubt  exist  in  the 
mind  of  the  physician  as  to  the  expediency  of  the  proced- 
ure at  the  particular  time,  by  a  prompt  resort  to  this  incis- 
ion, for  even  a  brief  delay  may  be  fatal  to  the  integrity  of 
the  testicle.  This  seemingly  violent  mode  of  treatment  was 
advocated  about  fifty  years  ago  by  Vidal  (de  Cassis),  who 
afterward  wished  to  generalize  it  in  all  forms  of  orchitis, 
and  made  incision  of  the  tunica  albuginea,  and  even  of  the 
parenchyma  of  the  testicle,  in  four  hundred  cases.  He  was 
criticised  with  undue  severity  by  Gosselin,  who  asserted  that 
the  incision  scarcely  ever  extended  beyond  the  tunica  vagi- 
nalis, and  that  the  relief  experienced  by  some  of  the  pa- 
tients so  treated  was  owing  to  the  exit  of  serous  fluid  which 
had  distended  the  tunica  vaginalis  and  had  been  the  chief 
cause  of  the  pain.    Vidal  did,  however,  accomplish  incision 


262 


of  the  tunica  albuginea  and  often  found  the  testicle  already- 
necrosed.  In  such  cases  incision  is  surely  indicated.  Hernia 
of  the  seminiferous  tubules  is  liable  to  occur  after  incision 
of  the  tunica  albuginea,  but  better  this  than  gangrene,  for 
under  favorable  circumstances  cicatrization  follows,  though 
the  testicle  is  more  or  less  damaged. 


263 


XI. 


Consequences  of  Acute  Urethritis  continued  ;  Gone- 
cystitis,  Tracheloctstitis,  Pyelitis,  Septicemia, 
Pyosaprjemia,  and  Rheumatism. 

,  The  investigations  upon  which  is  based  the  part  of  this 
conference  relating  to  the  seminal  vesicles  began  in  18V9, 
but  were  interrupted  by  other  occupations,  and  were  not 
resumed  until  the  year  1889.  The  majority  of  the  dissec- 
tions exhibited  were  made  during  1889,  1890,  and  1891. 
The  specimens  for  dissection  were  kindly  contributed  by  a 
number  of  medical  friends  interested  in  pathology. 

Gonecystitis — phlegmasia  of  the  seminal  vesicles — is 
of  much  more  frequent  occurrence  than  is  generally  sup- 
posed. It  exists  more  commonly  as  a  chronic  affection, 
often  associated  with  trachelocystitis  and  prostatitis,  for 
both  of  which  it  is  very  frequently  mistaken. 

Most  practicing  physicians  have  had  their  share  of  cases 
of  chronic  urethral  discharge  accompanied  with  phenomena 
variously  styled  "  genital  hypochondriasis,  sexual  neuras- 
thenia, diurnal  spermatorrhoea,  sterility,  impotency,"  etc. 
The  majority  of  these  are  cases  of  chronic  gonecystitis. 
Their  cure  is  very  difficult,  slow,  uncertain,  and  sometimes 
impossible.  It  is  not  easy  to  persuade  the  patients  that  the 
disease  is  local  and  that  there  is  no  great  danger  of  impli- 
cation of  other  organs.     Dwelling  much  upon  and  magni- 


264 


fying  their  infirmity,  tlieir  moral  condition  is  soon  not  a 
little  impaired.  They  are  often  unheedful  of  good  advice, 
and,  after  having  "  gone  the  rounds  "  of  the  regular  profes- 
sion, fall  into  the  meshes  of  greedy  charlatans,  while  some 
of  them  end  their  days  in  asylums  for  the  insane. 

In  its  acute  type  gonecystitis  frequently  occurs  as  one 
of  the  consequences  of  urethritis  with  orchitis.  It  is  then 
very  often  overlooked,  because  the  phenomena  of  the  or- 
chitis occupy  so  much  of  the  attention  of  the  patient  that 
the  subjective  symptoms  referable  to  the  region  of  these 
vesicles  are  masked  by  those  of  the  orchitis.  Therefore,  in 
order  to  ascertain  the  existence  or  non-existence  of  acute 
gonecystitis,  it  is  necessary  to  put  well-directed  questions  to 
patients  suffering  from  urethritis  and  consecutive  orchitis 
accompanied  by  abnormal  sensations  in  the  intrapelvic 
organs.  Prior  to  the  further  study  of  this  phlegmasia  it 
may  be  advantageous  to  rehearse  the  main  points  of  the 
anatomy  of  the  parts  involved. 

The  seminal  vesicles,  physiologically  considered, 
are  diverticula  of  the  spermatic  canals  serving  as  reservoirs 
of  the  semen  in  man  and  most  of  the  mammalia,  notwith- 
standing the  opinion  of  John  Hunter  to  the  contrary.  The 
assertion  that  the  seminal  vesicles  are  physiologically  diver- 
ticula of  the  spermatic  canals  is  based  upon  the  following 
facts :  The  dilated  part  of  the  spermatic  canals  correspond- 
ing in  longitudinal  extent  to  the  seminal  vesicles  is  iden- 
tical in  structure  with  the  seminal  vesicles ;  the  same  kind 
of  fibrous,  muscular,  and  mucous  coats  exist  in  both ;  the 


265 


mucous  coat  is  rugous  and  reticulated  and  lined  with  the 
same  tind  of  epithelium  in  both ;  the  same  kind  of  mucus 
is  secreted  by  the  same  kind  of  mucous  glands  in  both ; 
certain  expansions  and  diverticula  are  found  in  both ;  con- 
cretions abound  in  both  ;  and  both  are  tubular  in  character. 
The  anatomical  differences  are  :  The  tube  of  the  vesicles  is 
more  convoluted  than  the  spermatic  canals ;  the  walls  of 
the  vesicles  are  thinner  than  those  of  the  spermatic  canals ; 
the  caliber  of  the  tube  of  the  seminal  vesicles  is  greater 
than  that  of  the  spermatic  canals ;  and  the  seminal  vesicles 
have  twice  as  many  pouches  as  the  spermatic  canals.  Each 
vesicle  is  therefore  only  an  extension  of  the  spermatic  canal. 
In  some  animals — the  dog  kind,  for  instance — there  are  no 
seminal  vesicles,  the  slightly  expanded  extremity  of  the 
spermatic  canals  doing  all  that  is  necessary  toward  diluting 
the  semen  before  it  reaches  the  prostatic  region  of  the  ure- 
thra. The  seminal  vesicles  of  a  horse  dissected  in  1890  do 
not  consist,  as  in  man,  of  a  single  convoluted  tube  with 
diverticula,  but  each  vesicle  is  an  oblong  sac  capable  of  con- 
taining at  least  two  ounces  of  fluid.  The  mucous  membrane 
is  rugous  at  the  posterior  extremity  of  the  sac ;  the  re- 
mainder is  smooth. 

One  vesicle  lies  on  the  right  and  the  other  on  the  left  of 
the  median  line,  each  with  a  spermatic  canal  on  its  inner 
border,  widely  separated  posteriorly  and  converging  ante- 
riorly to  the  base  of  the  prostate,  which  is  traversed  by  their 
excretory  ducts,  and  to  which  their  anterior  extremities  are 
closely  united ;  the  vesicles  and  accompanying  spermatic 
canals  forming  two  sides  of  an  isosceles  triangle,  and  being 


266 

attached  to  tlie  lower  fundus  of  tlie  bladder,  witli  it  rest 
upon  the  rectum.  The  close  relations  of  the  vesicles  to  the 
prostate,  bladder,  rectum,  and  peritonaeum  explain  how 
these  parts  are  liable  to  be  reciprocally  involved  in  disease. 
When,  in  health,  the  bladder  is  empty,  the  space  between 
the  posterior  extremities  of  the  seminal  vesicles  is  two 
inches  and  three  quarters  in  extent,  but  while  this  part  of 
the  bladder  is  thus  increased  in  width  it  loses  in  antero- 
posterior extent,  for  the  peritonaeum  descends  to  within  half 
an  inch  of  the  base  of  the  prostate ;  and  in  some  cases  even 
overlaps  the  base  of  the  prostate.  When  the  bladder  fills 
up  with  urine  the  peritonaeum  ascends  with  it  and  this  an- 
tero-posterior  space  is  more  than  doubled,  while  the  trans- 
verse— i.  e.,  the  space  between  the  posterior  extremities  of 
the  seminal  vesicles — loses  three  quarters  of  an  inch. 

Each  vesicle  has  a  proper  fibrous  tunic,  and  the  two 
have  besides  a  common  fibrous  envelope  containing  a  con- 
siderable amount  of  smooth  muscular  tissue,  which  connects 
them  superiorly  with  the  bladder,  while  they  are  attached 
to  the  rectum  by  loose  connective  tissue.  The  vesicles  de- 
rive their  nutrition  from  branches  of  the  inferior  vesical 
and  middle  haemorrhoidal  arteries.  Their  veins  are  large, 
and  form  a  plexus  which  pours  its  blood  into  the  efferent 
veins  of  Santorini's  plexus,  and  which  renders  excision  of 
the  vesicles  so  bloody  and  dangerous  an  operation  as  it  has 
proved  to  be.  The  lymphatic  vessels  are  abundant  and  end 
in  two  or  three  trunks  on  each  side,  which  enter  certain 
glands  on  the  sides  of  the  pelvic  excavation.  The  nerves 
are  derived  from  the  hypogastric  plexus. 


267 

The  seminal  vesicles  are  conical  in  general  outline,  their 
bases  are  rounded  and  in  close  proximity  to  the  recto-vesi- 
cal  cul-de-sac  of  the  peritonaeum,  and  their  apices  are  buried 
in  the  base  of  the  prostate.  They  are  slightly  flattened 
superiorly  and  convex  inferiorly,  and  when  distended  show 
very  distinctly  their  convolutions,  which  are  bound  together 
by  connective  tissue.  They  measure  five  centimetres  (about 
two  inches)  in  length  and  when  unraveled  twelve  centi- 
metres (about  four  inches  and  three  quarters)  in  extreme 
length,  exclusive  of  their  eight  or  ten  diverticula.  The 
caliber  of  the  tube  of  the  vesicles  averages  six  millimetres. 
This  tube,  like  the  spermatic  canal,  is  made  up  of  three 
layers — an  external  fibrous,  very  thin  layer  ;  a  middle,  con- 
sisting of  smooth  muscular  tissue,  the  thickest  of  the  three  ; 
and  an  internal,  mucous  layer.  The  mucous  layer  is  ru- 
gous, alveolar,  lined  with  a  cubical  epithelium,  and  contains 
csecal  glands — such  as  are  found  in  the  terminal  part  of  the 
spermatic  canals.  These  glands  are  parallel  to  each  other, 
are  ordinarily  single,  but  here  and  there  are  double,  triple, 
quadruple,  or  even  quintuple,  converging  to  a  common  duct 
which  opens  between  the  rugae,  the  clear  mucoid  sub- 
stance they  secrete  serving  to  dilute  the  semen. 

Each  vesicle  has  its  excretory  duct,  which,  uniting  with 
the  spermatic  canal,  forms  the  common  ejaculatory  duct, 
which  is  about  sixteen  millimetres  in  length,  slightly  conical 
in  form,  and  opening  by  a  slit  on  each  side  of  the  veru 
montanum  on  the  floor  of  the  prostatic  region  of  the 
urethra.  The  caliber  of  the  common  ejaculatory  duct  is 
about  two  millimetres  at  its  upper  extremity,  decreasing  to 


268 

about  one  millimetre  at  its  terminal  extremity  in  the  urethra, 
and  is  extensible  to  a  considerable  degree.  Its  parietes  are 
very  thin  as  compared  with  those  of  the  seminal  vesicle,  and 
its  mucous  membrane  is  smooth. 

The  seminal  vesicles,  as  is  seen  from  their  peculiar  con- 
struction, serve  the  double  purpose  of  reservoirs  of  the 
semen  and  of  accessory  glands  to  the  genital  apparatus, 
their  alveoli,  diverticula,  and  convolutions  preventing  them 
from  completely  emptying  themselves  during  ejaculation. 
In  them  the  semen  is  detained  long  enough  not  only  to  be 
diluted  by  their  mucoid  secretion,  but  for  the  spermatozooids 
to  attain  full  maturity.  In  the  semen  of  men  given  to  ex- 
cessive sexual  intercourse,  immature  spermatozooids  have 
been  found  still  inclosed  in  their  parent  cells.  This  seems 
to  sustain  the  view  that  the  spermatozooids  do  not  reach 
perfection  until  they  have  lingered  for  a  time  in  the  lower 
part  of  the  spermatic  canals  and  in  the  seminal  vesicles. 

Besides  secreting  the  mucoid  substance  already  referred 
to,  the  seminal  vesicles  contain  certain  very  small  calcareous 
concretions,  few  in  number  and  not  constantly  found  except 
in  disease.  Civiale  mentions  Carmann,  Riedlin,  Stalpart 
Vander  Wiel,  Hartmann,  Meckel,  Hemman,  and  Baillie  as 
having  cited  examples  of  calculous  concretions  formed  in  the 
seminal  vesicles,  and  likewise  names  Mitchell  as  having  found 
two  hundred  small  calculi,  of  earthy  appearance,  in  the  right 
seminal  vesicle  of  a  phthisical,  subject.  Eokitansky  also 
speaks  of  the  presence  of  calculous  concretions  in  the  semi- 
nal vesicles.  In  addition  to  these  calculous  particles,  there 
is  a  great  abundance  of  other  concretions,  irregular  in  form 


269 


and.  size,  nearly  colorless  in  health,  amber- colored  in  dis- 
ease, very  friable,  and  resembling  inspissated  mucus. 
These  last-named  concretions,  whose  use  is  unknown,  were 
carefully  studied  by  Ch.  Robin,  who  called  them  sympexia, 
which  means  concretions,  and  who  thought  them  analo- 
gous to  the  concretions  found  in  the  thyreoid  body,  the 
spleen,  the  glands  of  the  uterus,  the  lymphatic  glands,  and 
the  prostate.  These  sympexia  are  found  in  great  quantities 
also  in  the  expanded  extremities  of  the  spermatic  canals. 
Microscopic  in  dimensions,  they  are  lodged  in  the  alveoli  of 
the  mucous  membrane,  increase  in  size  from  phlegmasia  of 
this  membrane,  and  become  sources  of  further  irritation, 
and  even  obstruct  the  excretory  duct,  as  observed  in  some 
of  the  specimens  exhibited.  In  these  specimens  they  vary 
from  one  to  four  millimetres  in  mean  diameter,  and  among 
the  specimens  illustrating  chronic  gonecystitis  many  are 
oblong,  like  grains  of  rice,  three  by  eight  millimetres  in 
dimensions.  The  large  sympexia  sometimes  consist  of  ag- 
gregations of  small  concretions  cemented  by  pus  and  im- 
prisoning spermatozooids,  blood,  and  epithelial  cells.  They 
fly  to  pieces  on  slight  pressure. 

The  normal  seminal  vesicles  of  a  man,  aged  thirty-nine 
years,  who  died  of  pneumonia,  were  carefully  dissected 
and  the  contents  of  the  left  vesicle  examined  microscopically, 
with  the  following  results :  The  fluid  was  viscid,  of  a 
brownish  color,  and  consisted  of  mucus,  with  innumerable 
spermatozooids,  spermatic  cells,  leucocytes,  a  few  cubical 
epithelial  cells,  and  great  numbers  of  sympexia  of  a  yellow- 
ish color,  globular  in  form,  some  of  them  about  half  the 


270 


diameter  of  red  blood-corpuscles,  others  of  nearly  the  size 
of  red  corpuscles.  Here  and  there  these  sympexia  were 
aggregated  in  masses  from  the  one  five-hundredth  to  the 
one  three-hundredth  of  an  inch  in  size. 

The  viscid,  brownish  contents  of  the  seminal  vesicles  of 
a  man,  seventy-three  years  of  age,  who  died  of  a  head  in- 
jury, examined  microscopically,  twenty-four  hours  after 
death,  consisted  of  epithelial  cells  of  difEerent  form ;  some 
were  polygonal,  some  cubical,  some  oval ;  a  few  spermatic 
cells,  many  sympexia  of  amber-color,  varying  in  size  from 
one  third  the  diameter  of  red  blood-cells  to  the  size  of 
leucocytes ;  some  of  them  were  round,  the  majority  poly- 
hedral and  irregular,  and  the  smallest  were  often  aggregated 
in  masses  of  four,  six,  eight,  or  ten.  No  spermatozooids 
were  discerned.  Other  observations  gave  similar  results. 
The  cubical  character  of  the  epithelium  and  the  existence 
of  mucous  glands  were  verified  in  the  vesicles  as  well  as  in 
the  spermatic  canals. 

GoNECTSTiTis  docs  not  appear  to  have  attracted  much 
attention  until  Lallemand  published  his  observations  of  this 
affection  in  connection  with  "spermatorrhoea,"  which  is 
often  one  of  its  phenomena,  while  some  form  of  urethritis 
is  almost  invariably  its  exciting  cause.  Civiale,  Vidal, 
Gosselin,  Verneuil,  Fournier,  Rapin,  and  other  authors, 
French,  German,  English,  and  American,  have,  to  a  greater 
or  less  extent,  discussed  the  question  of  phlegmasia  of  the 
seminal  vesicles  in  special  essays,  general  surgical  treatises, 
inaugural  theses,  or  journal  articles.     Among   the  essays 


271 


that  have  appeared  in  the  last  few  years  upon  this  topic  is 
a  paper  with  the  title  of  Seminal  Vesiculitis,  by  Mr.  Jordan 
Lloyd,  of  Birmingham,  in  the  British  Medical  Journal, 
April  20,  1889.  Each  of  these  writers  has  contributed  his 
share  toward  the  elucidation  of  the  subject,  but  much  re- 
mains to  be  done  by  other  laborers. 

Gonecystitis  seems  to  occur  with  greatest  frequency 
among  men  who  habitually  commit  venereal  excesses, 
and  among  those  addicted  to  masturbation,  either  render- 
ing the  seminal  vesicles  more  or  less  vulnerable.  This 
vulnerability  generally  consists  in  abnormal  expansion  of 
the  ejaculatory  ducts,  or  in  persistent  erethism  of  their 
mucous  membrane  and  that  of  the  seminal  vesicles.  Acute 
phlegmasia  of  the  urethra  in  such  subjects  is  thus  propa- 
gated through  the  ejaculatory  duct  to  the  seminal  vesicle 
and  spermatic  canal  on  one  or  both  sides,  generally  accom- 
panying orchitis,  but  sometimes  without  the  association  of 
orchitis,  just  as  orchitis  often  occurs  without  involvement 
of  the  vesicle.  It  arises  most  commonly  as  a  consequence 
of  chronic  urethritis,  but  violent  catheterism  is  not  in- 
frequently its  exciting  cause,  particularly  when  a  very 
small  instrument  enters  or  tears  the  ejaculatory  duct. 

In  the  acute  types  of  gonecystitis  the  mucous  membrane 
of  the  ejaculatory  duct  may  be  swollen  to  the  extent  of  oc- 
cluding its  lumen,  or  a  large  sympexion  may  be  dislodged 
from  the  vesicle,  forced  into,  and  plug  the  ejaculatory  duct, 
so  that  in  either  case  pus  may  accumulate  and  greatly  dis- 
tend the  vesicle  whose  attenuated,  or  perhaps  ulcerated, 
walls  are  linally  perforated,  possibly  at  several  points,  allow- 


272 


ing  this  pus  to  infiltrate  the  ambient  connective  tissue  and 
to  form  a  vast  abscess  pointing  in  the  direction  of  the 
ischio-rectal  fossa,  of  the  bladder,  of  the  rectum,  or  even 
of  the  peritonaeum.  This  process  belongs  generally  to 
superacute  or  to  acute  phlegmasia.  In  the  case  of  subacute 
phlegmasia  there  is  a  minor  degree  of  swelling ;  resolu- 
tion being  slow  or  failing,  there  follows  chronic  gonecystitis, 
interstitial  as  well  as  parenchymatous. 

In  the  chronic  type  there  is  sometimes  ectasia  of  the  vesi- 
cles, which  contain  large  sympexia,  as  shown  in  several  of 
the  thirty-four  carefully  dissected  specimens  exhibited,  or 
the  vesicle  shrivels  sometimes  in  an  extraordinary  degree, 
as  seen  in  three  of  the  specimens,  and  becomes  useless.  One 
specimen  illustrates  three  interesting  points  :  occlusion  of 
the  right  spermatic  canal,  shriveling  of  its  accompanying 
seminal  vesicle,  and  apparently  compensatory  enlargement 
of  the  left  vesicle  and  spermatic  canal.  Another  specimen 
also  illustrates  occlusion  of  the  right  spermatic  canal,  but 
probably  of  recent  date,  because  the  seminal  vesicle  does  not 
appear  to  have  undergone  the  shriveling  process. 

Interstitial  is  generally  secondary  to  parenchymatous 
phlegmasia  of  the  vesicle  and  is  characterized  by  plastic  in- 
filtration of  the  intertubular  connective  tissue.  Suppura- 
tion may  take  place  primarily  in  the  intertubular  connective 
tissue,  but  this  can  occur  only  from  the  destructive  action 
of  a  sudden  and  superabundant  exudate.  Generally  the  exu- 
date becomes  imperfectly  organized,  undergoes  sclerous  de- 
generation, and  the  vesicle  shrivels.  Sometimes  the  exudate 
is  better  organized  and  the  vesicle  remains  large  and  is  some- 


273 


what  indurated.  Several  of  the  specimens  presented  illus- 
trate this  point  and  show  both  vesicles  to  he  considerably 
enlarged,  hard,  and  filled  with  large  sympexia.  The  shriv- 
eled condition  of  the  seminal  vesicles  is  common  in  cases 
of  prostatic  enlargement  demanding  frequent  evacuative 
catheterism  of  the  bladder  for  several  years,  the  patients 
having  had  repeated  attacks  of  orchitis  with  involvement 
of  both  vesicles. 

Of  sixty  dissections  of  the  seminal  vesicles  made  in  cases 
of  prostatic  enlargement,  three  fourths  of  these  vesicles  were 
shriveled  and  hard.  The  remainder,  though  not  diminished 
in  size,  were  more  or  less  indurated.  In  a  few  instances 
they  were  enlarged,  and  in  one  case  they  were  cancerous. 
In  a  specimen  recently  dissected,  both  vesicles  were  found 
reduced  to  less  than  half  of  their  normal  size  and  were  near- 
ly as  hard  as  cartilage.  A  longitudinal  incision  made  into 
the  left  vesicle  showed  the  lumen  of  its  tube  to  be  reduced 
to  about  two  millimetres  in  diameter,  except  at  the  poste- 
rior extremity  of  the  vesicle,  where  its  walls  were  attenuated, 
translucent,  and  expanded  into  a  cyst  containing  three 
grammes  of  limpid  fluid.  The  right  vesicle,  which  was  not 
incised,  presented  the  same  external  appearances  as  the  left. 
The  prostate  was  considerably  increased  in  size,  very  hard, 
and  had  for  several  years  impeded  urination.  The  patient 
died  in  consequence  of  pyelonephritis. 

The  sym'ptoms  of  acute  gonecystitis  so  far  observed  are  : 

Almost  constant  painful  erections  of  the  penis  ;  frequent  and 

painful  ejaculations  of  semen  mixed  with  pus  and  blood, 

until  the  ejaculatory  duct  is  occluded,  when  spermatic  colic 
18 


274 

occurs  ;  pain  extending  along  the  urethra  to  the  extremity 
of  the  penis  (this,  however,  is  an  index  of  coexistent  trachel- 
ocystitis)  ;  difficult,  painful,  and  frequent  urination  ;  burn- 
ing pain  in  the  perinteum,  at  the  anus,  and  at  the  lower  end 
of  the  rectum  ;  a  sense  of  tension  in  the  rectum  ;  rectal  te- 
nesmus ;  and  very  painful  defecation.  Rigors  and  febrile 
reaction,  and  throbbing  pains  in  the  rectum  indicate  suppu- 
ration. Retention  of  urine  sometimes  occurs  in  case  of  great 
tumefaction  of  one  or  both  vesicles. 

The  diagnosis  of  acute  gonecystitis  is  arrived  at  by  an 
analysis  of  the  symptoms,  by  digital  examination  through 
the  rectum,  and  by  intra-urethral  instrumental  exploration. 
The  digital  examination  reveals  more  or  less  tumefaction, 
heat,  and  tenderness  in  the  region  of  the  vesicles  on  one  or 
both  sides  as  the  case  may  be.  If  the  swelling  is  in  the 
form  of  a  single,  hard,  oblong  tumor  extending  from  the 
base  of  the  prostate  upward,  backward,  and  outward,  the 
presumption  is  that  the  phlegmasic  process  has  not  extended 
beyond  the  proper  capsule  of  one  seminal  vesicle.  If,  how- 
ever, there  is  a  diffuse,  doughy  swelling  extending  beyond 
the  median  line,  it  is  likely  that  both  vesicles  are  involved, 
that  perforation  of  their  walls  has  taken  place,  and  that  the 
ambient  connective  tissue  is  infiltrated.  When  one  vesicle 
only  is  involved  in  suppuration  together  with  the  prerectal 
connective  tissue,  the  pus  sometimes  points  in  the  direction 
of  the  ischio-rectal  fossa.  In  such  cases  the  digital  exami- 
nation indicates  the  lateral  deviation  of  the  abscess.  The 
instrumental  urethral  exploration  should  be  made  first  by 
introducing  a  gum  catheter  with  the  object  of  emptying  the 


275 


bladder.  This  done,  a  moderate-sized  rectangular  steel 
sound  should  be  carefully  introduced.  Though  the  first 
catheterism  may  have  given  some  pain,  the  moment  the 
sound  reaches  and  distends  the  prostatic  region  of  the  ure- 
thra and  passes  over  the  veru  montanum  the  most  acute 
burning  pain  is  experienced  and  continues  as  long  as  the 
instrument  is  retained.  Without  loss  of  time  a  finger  should 
be  passed  into  the  rectum  and  pressure  made  along  the  me- 
dian line  of  the  prostate  in  order  to  break  up  and  cause  the 
expulsion  of  a  sympexion  which  may  be  plugging  the  ejacu- 
latory  duct.  Several  of  the  symptoms  being  common  to 
acute  prostatitis,  the  rectal  and  urethral  explorations  are 
necessary  to  distinguish  acute  gonecystitis  from  acute  pros- 
tatitis. The  connections  of  the  ejaculatory  ducts  with  the 
urethra,  the  seminal  vesicles,  and  the  spermatic  canals  ex- 
plain how  gonecystitis  and  orchitis  may  occur  at  the  same 
time.  But,  as  before  stated,  the  phenomena  of  the  orchitis 
are  generally  such  as  to  mask  those  of  the  gonecystitis.  It 
is  therefore  wise  in  most  cases  of  orchitis  to  make  by  the 
rectum  a  digital  exploration  of  the  seminal  vesicles,  which, 
if  found  tender  to  pressure,  swollen,  and  hot,  should  be 
treated  accordingly. 

In  the  treatment  of  the  acute  types  of  gonecystitis  the 
chief  indication  is  to  prevent  interstitial  suppuration.  For 
this  end  a  similar  course  to  that  pursued  in  acute  prostatitis 
should  be  adopted.  After  thoroughly  cleansing  the  rectum, 
three  or  four  leeches  may  be  applied  to  its  mucous  mem- 
brane in  the  region  of  the  affected  vesicle,  with  the  aid  of  a 
tube  such  as  that  recommended  by  Dr.  Hughes,  of  Dublin, 


276 

for  leeching  in  acute  prostatitis.  When  the  well-gorged 
leeches  have  cast  themselves  away,  irrigation  of  the  rectum 
with  warm  water  should  be  made  until  it  is  judged  that  a 
sufficient  quantity  of  blood  has  been  lost.  If  it  is  found 
impracticable  to  leech  by  way  of  the  rectum,  a  greater 
number  of  leeches — ten  or  twelve — may  be  applied  to  the 
anal  and  perineal  regions.  Enough  blood  will  thus  be  drawn 
to  unload  the  congested  prerectal  plexus  of  veins.  As  soon 
as  possible  after  either  of  these  modes  of  local  depletion, 
the  lower  end  of  the  rectum  should  be  packed  with  cracked 
ice.  When  the  ice  melts,  the  water  is  allowed  to  flow  out, 
while  the  anus  is  stretched  open  for  the  introduction  of 
more  ice  suppositories,  a  process  to  be  repeated  at  least 
every  hour  while  the  patient  is  awake.  These  frequent  ap 
plications  of  ice  should  be  continued  two  or  three  days,  and 
longer  if  necessary. 

This  antiphlogistic  treatment  is  valuable  only  during  the 
period  of  increase  or  of  stasis  of  the  phleg-masia.  Begun 
later,  it  is  apt  to  be  worse  than  useless.  If,  however,  it  is 
employed  at  the  right  time  and  faithfully  carried  out,  much 
suffering  is  prevented,  and  resolution  is  likely  to  be  hast- 
ened. Otherwise  suppuration  occurs,  and,  to  prevent  the 
pus  from  finding  an  outlet  which  may  be  dangerous  to  the 
patient,  the  sooner  a  free  exit  is  artificially  given  to  this 
pus  the  better  for  his  safety.  The  particular  process  of  re- 
lief should  be  adapted  to  the  condition  of  the  individual 
and  to  the  extent  of  the  abscess.  When  it  is  ascertained 
by  digital  exploration  that  the  abscess  is  not  large  but  well 
defined  on  one  side  or  the  other  of  the  median  line,  the 


277 

presumption  is  tliat  the  pus  has  not  passed  beyond  the 
boundary  of  the  proper  fibrous  capsule  of  one  vesicle.  In 
such  a  case  aspiration  through  the  rectal  walls  is  indicated. 
The  parts  should  be  brought  to  view  by  means  of  a  Sims 
speculum,  and  a  slightly  curved  aspirating  needle,  not  less 
than  two  millimetres  in  caliber,  should  be  thrust  into  the 
abscess  and  the  cavity  quickly  emptied  and  then  well  irri- 
gated with  a  warm  sublimate  solution  (one  to  five  thousand). 
A  single  aspiration  may  suffice  ;  but  in  case  the  cavity  refills, 
the  aspiration  and  irrigation  should  be  repeated.  If  from 
superacute  phlegmasia  there  is  reason  to  believe  that  much 
necrosis  of  the  tissues  has  occurred,  or  if  the  pus  has 
broken  through  all  barriers  and  has  already  infiltrated  the 
prerectal  connective  tissue,  a  Sims  speculum  should  be  in- 
troduced, and  a  free  incision  through  the  wall  of  the  rec- 
tum should  be  made  into  the  abscess,  whose  cavity  should 
be  well  disinfected  and  lightly  packed  with  a  tent  of  anti- 
septic gauze.  This  dressing  to  be  renewed  every  day. 
Whenever  the  abscess  is  large,  and  this  is  generally  the  case 
when  it  has  been  of  very  slow  development,  almost  chronic, 
it  is  likely  to  point  laterally  toward  the  ischio-rectal  fossa. 
In  that  case  it  should  be  reached  by  the  way  of  the  peri- 
naeum,  as  suggested  by  Mr.  Lloyd.  The  incision  may  be 
central  or  lateral,  and  directed  so  as  to  avoid  the  urethra 
and  rectum.  In  case  of  doubt — that  is  to  say,  in  case,  from 
the  extent  of  the  purulent  collection,  there  is  a  suspicion 
that  both  vesicles  are  affected — it  is  wise  to  make  a  crescentic 
incision  three  quarters  of  an  inch  in  front  of  the  anal  mar- 
gin and  deepen  the  cut  by  careful  dissection  between  the 


278 


rectum  and  prostate,  care  being  taken  to  avoid  wounding 
the  urethra.  After  giving  free  vent  to  tlie  pus,  tlie  abscess 
cavity  should  be  disinfected  and  very  loosely  packed  with 
a  tent  of  antiseptic  gauze,  so  that  the  healing  process  may 
begin  at  the  bottom  of  the  cavity. 

Chronic  Gonectstitis. — Though  acute  gonecystitis 
often  resolves  without  suppuration,  it  becomes  chronic  in  a 
considerable  proportion  of  cases,  while  in  a  great  majority 
of  instances  chronic  gonecystitis  begins  independently  of 
the  acute  types. 

The  common  causes  of  chronic  gonecystitis  are  venereal 
excesses  and  masturbation,  both  giving  rise  to  chronic  ure- 
thritis, which  is  the  immediate  cause. 

The  symptoms  of  the  chronic  are  similar  to  those  of  the 
acute  type,  but  the  suffering  is  less,  and  there  is  no  febrile 
reaction.  One  of  the  most  constant  symptoms  is  a  burning, 
itching  sensation  in  the  perinaeum,  anus,  and  rectum,  such 
as  occurs  in  the  acute  type,  but  not  so  intense,  though 
continuous  in  some  cases,  and  very  harassing  month  after 
month  and  year  after  year.  Another  phenomenon  is  pain- 
ful spasmodic  contracture  of  the  anal  sphincter.  When  a 
seminal  vesicle  is  in  a  chronic  phlegmasic  state,  there  is 
often  a  persistent  urethral  discharge  consisting  of  pus,  a 
little  blood,  some  epithelium,  and  a  few  dead  spermato- 
zooids. 

Spermatic  colic  is  another,  though  not  very  frequent, 
symptom  of  chronic  gonecystitis.  It  is  due  to  the  lodg- 
ment of  a    large  sympexion  in  the   ejaculatory   duct  and 


279 


consequent  retention  of  semen,  raucus,  and  pus  in  the  semi- 
nal vesicle. 

Pus  intimately  mixed  witli  semen  is  regarded  by  Chris- 
tian Smith  as  a  pathognomonic  symptom  of  chronic  phleg- 
masia of  the  seminal  vesicles.  The  only  means,  says  Dr. 
Smith,  of  ascertaining  the  source  of  this  pus  is  by  examin- 
ing the  semen  that  has  dried  on  the  patient's  linen  after 
coitus  or  after  an  involuntary  pollution.  "  The  stain  made 
upon  linen  by  normal  semen  is  of  a  uniform  grayish-white 
with  a  darker  border,  which  never  contains  any  element  of 
yellow,  while  in  case  of  phlegmasia  of  the  seminal  tract  the 
dried  stain  presents  a  more  or  less  yellow  coloring,  either 
throughout  or  at  the  border,  which  is  the  most  highly 
colored.  When  the  pus  originates  in  the  urethral  or  pros- 
tatic crypts,  its  mixture  is  never  so  intimate  as  in  the  first 
case,  and  the  yellow  coloring  shows  itself  in  minute  zones 
or  in  disseminated  spots  upon  the  gray  stain." 

Progress. — When,  in  the  chronic  type  of  gonecystitis, 
the  ejaculatory  duct  becomes  occluded,  the  secretions  gTadu- 
ally  accumulate  and  cause  ectasia  of  the  vesicle  and  some- 
times also  of  the  spermatic  canal.  Such  cases  are  of  rare 
occurrence,  and  their  symptoms  are  not  easily  interpreted. 

Dr.  Nathan  R.  Smith,  of  Baltimore,  reported  in  the 
Lancet^  1872,  vol.  ii,  p.  558,  with  the  title  of  Hydrocele  of 
the  Seminal  Vesicle,  a  case  of  cyst  of  the  left  seminal  vesi- 
cle which  filled  the  pelvis  and  extended  into  the  abdominal 
cavity  to  a  point  above  the  umbilicus,  and  was  at  first  mis- 
taken for  retention  of  urine.  The  cyst  was  tapped  by  the 
rectum  and  ten  pints  of  a  brown  serous  fluid  were  drawn. 


280 


In  four  weeks  the  cyst  filled  again  and  was  again  tapped. 
This  time  it  did  not  refill.  Reference  to  this  case  is  made 
by  Mr.  Lloyd. 

A  remarkable  example  of  ectasia  of  the  spermatic  canal 
is  recorded  by  Troussel-Delvincourt  in  the  Nouveau  journal 
de  medecine,  October,  1820.  The  right  spermatic  canal 
formed  a  cylinder  measuring  nearly  two  inches  in  diameter, 
soft,  smooth,  filled  with  a  thick,  pulpy,  yellow  material, 
similar  to  that  of  softened  tubercle.  The  seminal  vesicles 
contained  a  similar  but  less  consistent  material. 

These  two  are  very  exceptional  cases,  the  ectasia  rarely 
exceeding  twice  the  normal  caliber  of  the  vesicle  and  canal, 
as  shown  by  the  specimens  exhibited. 

Subacute  and  chronic  iMegriw.sia  sometimes  end  in  cal- 
careous infiltration  of  one  or  both  vesicles  and  spermatic 
canals.  Among  the  specimens  exhibited  is  a  good  illustra- 
tion of  calcareous  infiltration  of  the  spermatic  canals. 

Since  ■phlegmasia  of  the  spermatic  canal  is  ordinarily  as- 
sociated with  gonecystitis,  sterility  is  one  of  the  sequels  of 
the  chronic  type  when  both  sides  are  affected,  the  sperma- 
tozooids  being  destroyed  by  the  abnormal  secretions  of 
the  spermatic  canals  and  seminal  vesicles.  When  the  two 
spermatic  canals  or  the  two  ejaculatory  ducts  are  perma- 
nently occluded,  impotency  is  the  result,  erection  of  the 
penis  being  imperfect  and  sexual  desire  finally  extinct. 

In  elderly  men,  as  seen  by  the  results  of  the  dissection 
of  sixty  pairs  of  seminal  vesicles,  there  is  often  shriveling 
of  the  vesicles  from  chronic  phlegmasia.  In  younger  sub- 
jects the  chronic  phleginasia  is  generally  confined  to  the 


281 


mucous  membrane  and  tlie  vesicles  are  more  likely  to  be 
dilated  and  filled  witli  large  sympexia.  In  several  of  the 
thirty-four  dissections  first  mentioned  a  sympexion  was 
found  blocking-  the  ejaculatory  duct.  In  these  younger 
subjects  the  symptoms  are  ordinarily  distinct,  while  in 
elderly  persons  they  are  frequently  wanting,  and  the  al- 
tered condition  of  the  vesicles  is  ascertained  only  at  the 
necropsy. 

The  treatment  of  chronic  gonecystitis  should  consist  in 
endeavors  to  cure  the  existing  chronic  urethritis,  and  in 
emptying  the  distended  vesicle  every  day  by  pressure  with 
the  finger  passed  into  the  rectum.  This  may  be  followed 
by  very  warm  enemata  and  the  occasional  use  of  rectal  sup- 
positories containing  half  a  grain  of  belladonna  extract  and 
one  grain  of  opium.  From  time  to  time  the  passage  of  a 
steel  sound  and  digital  pressure  thereon  through  the  rectum 
should  be  resorted  to  for  the  purpose  of  effecting  the  ex- 
pulsion of  sympexia  from  the  ejaculatory  duct.  The  pro- 
cess should  be  employed  as  well  for  purposes  of  diagnosis 
as  for  relief  at  the  same  time,  the  extraction  of  the  sym- 
pexion allowing  the  distended  vesicle  to  be  emptied  and 
relieving  a  painful  spermatic  colic. 

Trachelocystitis — phlegmasia  of  the  neck  of  the  blad- 
der— having  already  been  examined,  needs  now  only  to  be 
named  as  a  consequence  of  urethritis. 

Pyelitis  and  nephritis  very  rarely  occur  in  conse- 
quence of  acute  urethritis  and  are  generally  indirectly  caused 
by  urethritis— that  is  to  say,  they  are  among  the  ill  effects 


282 


of  imprudent  treatment,  such  as  tlie  long  continuance  of 
balsamics  in  excessive  doses,  particularly  copaiba  balsam, 
wbich.  has  been  known  to  cause  acute  parenchymatous  ne- 
phritis and  pyelitis,  and  finally  chronic  diffuse  nephritis 
with  albuminuria.  Balsamics  can  not  be  too  cautiously  em- 
ployed in  the  treatment  of  urethritis.  The  use  of  copaiba, 
or  any  other  balsamic,  should  be  discontinued,  and  on  no 
account  resumed,  in  the  cases  which  show  their  suscepti- 
bility to  its  toxic  effects  by  a  profuse  exanthem,  an  urti- 
caria, or  a  papular  eruption  on  the  face  and  body.  These 
are  the  cases  which  are  likely  to  be  complicated  with  ne- 
phritis. Some  observers  think  they  have  detected  a  mild 
subacute  pyelitis  in  the  majority  of  cases  of  urethritis, 
whether  acute  or  chronic.  May  not  this  pyelitis  be  owing 
to  the  heroic  treatment  too  often  employed  in  the  manage- 
ment of  the  several  types  of  urethritis  ? 

Septicaemia  and  pyosapr^mia  very  seldom  occur  as 
consequences  of  urethritis. 

Septiccemia — putrid  infection  of  the  blood — is  due  to 
the  evolution  of  ptomaines  or  of  leucomaines,  the  first 
being  the  product  of  bacterial  ferments  developed  in  parts 
of  the  body  that  have  become  putrescent  from  injury,  the 
second  indigenous  to  the  body  and  evolved  in  disease  in- 
dependently of  bacterial  ferments.  Septicaemia  consequent 
upon  urethritis  is  probably  sometimes  a  leucomainal  intoxi- 
cation, and  is  manifested  by  a  violent  rigor  with  much  con- 
stitutional disturbance  in  some  cases  of  superacute  ure- 
thritis.    This  intoxication  may  be  so  profound  as  to  be 


283 

uncontrollable.  In  all  cases  there  is  constitutional  disturb- 
ance, but  in  the  majority  it  is  of  comparatively  minor  in- 
tensity. The  poison  is  apparently  less  virulent,  but  this 
lesser  virulence  is  rather  in  degree  than  in  kind.  Neverthe- 
less, the  poison  is  very  gradually  eliminated,  and  the  suf- 
ferer— pale,  emaciated,  and  feeble — makes  a  slow,  lingering 
recovery,  convalescence  requiring  six  or  eight  weeks.  In 
the  first-named  type  of  cases  the  indication  is  to  insure 
rapid  elimination  of  the  poison.  To  that  end  free  catharsis, 
diuresis,  and  diaphoresis  should  be  promptly  established, 
and  during  the  action  of  the  remedies  employed  the  vital 
powers  should  be  sustained  by  stimulants  and  reconstitu- 
ents.  If  these  means  are  successful,  the  case  may  be  man- 
aged as  in  the  second  type,  which  permits  the  more  delib- 
erate selection  of  agents  likely  to  safely  expedite  the  elimi- 
nation of  the  poison.  The  cathartics  should  be  replaced 
by  aperients,  and  the  diaphoretics  and  diuretics  should  be 
mild,  but  continued  two  or  three  weeks.  Five  grains  of 
chloride  of  ammonium  thrice  daily,  and  ten  minims  of 
tincture  of  chloride  of  iron,  both  largely  diluted,  should  be 
given  from  the  beginning  to  the  end  of  convalescence.  The 
diet  should  be  mild,  but  nourishing  and  easily  digested. 
Milk  at  first,  then  more  substantial  food,  and  generous 
wines. 

Pyosaproemia — putrid  pus  infection  of  the  blood — dif- 
fers from  septicaemia  clinically  and  pathically.  Septicaemia 
often  occurs  before  the  formation  of  pus,  while  pyosaprae- 
mia  may  not  be  manifested  until  several  weeks  after  the  in- 
fliction of  a  wound  or  the  formation  of  an  abscess.     In 


284 

septicaemia  there  are  generally  no  secondary  abscesses.  In 
pyosapraemia,  infective  thrombi  swarming  with  micro-organ- 
isms are  found  in  tlie  neighboring  veins  and  carried  into  the 
circulation  to  cause  multiple  abscesses,  sometimes  in  the 
viscera,  sometimes  in  other  parts  of  the  body  distant  from 
the  point  of  injury.  These  thrombi  contain  great  numbers 
of  staphylococci  and  streptococci.  The  favorable  cases  are 
generally  those  in  which  the  viscera  have  escaped  contami- 
nation, and  the  thrombi  have  lodged  in  muscles  or  in  super- 
ficial connective  tissue. 

Pyosapraemia  occurs  as  a  consequence  of  urethritis  in 
case  of  a  solution  of  continuity,  as  occurs  from  "  breaking 
the  chordee,"  or  from  some  other  injury,  or  in  case  of  ab- 
scess in  any  part  of  the  urogenital  tract.  In  these  two 
circumstances  infective  thrombi  are  formed  in  the  ambient 
veins  and  their  migration  begins.  Septicaemia  is  mani- 
fested by  one  violent  rigor  and  much  febrile  reaction,  while 
pyosapraemia  is  characterized  by  recurring  slight  rigors  of 
short  duration,  with  less  febrile  reaction  than  septicaemia. 
When  death  occurs  in  consequence  of  acute  urethritis  there 
is  either  septicaemia  or  pyosapraemia.  It  is  almost  impos- 
sible to  ascertain  the  percentage  of  mortality  from  these 
causes,  for  such  cases  are  very  seldom  reported. 

A  few  years  ago,  at  Bellevue  Hospital,  a  death  occurred, 
which  may  be  regarded  as  an  excellent  illustration  of  pyo- 
sapraemia originating  from  urethritis.  The  subject  of  this 
affection  was  a  boy,  seventeen  years  of  age,  who  was  suffer- 
ing from  superacute  urethritis  and  a  consequent  perineal 
abscess.     He  had  slight  recurring  rigors  and  other  signs 


285 


of  profound  pyosapraemia,  and  died  three  weeks  after  his 
admission  to  the  hospital. 

Kheumatism  as  an  occasional  consequence  of  urethritis, 
occurring  in  a  little  less  than  two  per  cent,  of  all  cases,  was 
first  specialized  in  the  latter  part  of  the  last  century  (1781) 
by  Swediaur  and  by  Selle.  Swediaur's  chapter  on  the  sub- 
ject is  short,  bears  the  title  of  Arthrocele,  Gronocele,  or 
Blennorrhag'ic  Swelling  of  the  Knee,  and  begins  as  fol- 
lows :  "  A  very  considerable  swelling  of  the  knee,  some- 
times of  both  knees  and  the  heel  at  once,  attended  by  ex- 
cruciating pains  in  the  joint,  sometimes  occurs  in  men  after 
a  blennorrhagia.  These  pains,  accompanied  by  more  or 
less  symptomatic  fever,  continue  for  two  or  three  weeks, 
and  gradually  go  ofE,  leaving  a'  stiffness  in  the  joint,  which 
lasts  for  many  months.  The  disease  particularly  affects 
young  men  who,  after  a  debauch,  have  been  infected  with 
blennorrhagia,  with  which  it  seems  to  be  intimately  con- 
nected. ...  It  is  not  very  uncommon,  for  in  the  course  of 
my  practice  I  have  seen  six  or  eight  cases,  each  of  which 
came  on  about  the  eighth  or  sixth  day  of  the  blennorrhagia, 
and  in  every  instance  the  discharge  from  the  urethra  was 
either  sensibly  diminished  or  totally  suppressed.  For  want 
of  sufficient  observation,  I  have  not  been  able  to  determine 
the  character  of  this  disease  ;  but  in  all  the  cases  which 
have  come  within  my  knowledge  the  disease  appeared  to 
partake  of  the  character  of  gout,  with  this  exception,  that 
all  the  persons  were  about  the  age  of  twenty-three  or  thirty, 
that  the  color  of  the  skin  was  not  changed,  and  that  the 


286 


swelling  bore  handling  witliout  exciting  pain.  The  swell- 
ing gradually  disappears  by  the  free  use  of  diluting  drinks 
and  by  frictions  with  the  ammoniacal  liniment.  .  .  ."  This 
laconic  description  contains  nearly  all  that  is  now  known 
of  the  gross  pathology,  aetiology,  diagnosis,  and  therapeusis 
of  the  affection.  Additions,  but  no  subtractions,  have  been 
made  to  Swediaur's  chapter  by  more  than  three  hundred 
writers  on  the  subject  since  his  time. 

The  character  of  these  additions  is  far  from  exhibiting 
a  general  consensus  of  views  respecting  the  nature  of 
"  urethral  rheumatism,"  which  still  remains  unexplained. 

A  synoptical  presentation  of  a  few  of  these  diverse  views 
will  answer  the  purpose  of  this  conference. 

Swediaur,  Lagneau,  and  Cullerier  attributed  "  urethral 
rheumatism  "  to  metastasis,  and  the  aiiection  was  afterward 
treated  in  accordance  with  that  hypothesis. 

There  are  others  who  thought  "urethral  rheumatism" 
to  be  the  effect  of  the  cubeb  and  copaiba  treatment  of  ure- 
thritis. Still  others,  among  whom  are  several  French,  Eng- 
lish, and  American  writers,  have  regarded  "  urethral  rheu- 
matism "  as  one  of  the  effects  of  pyosapra?mia. 

Fereol  spoke  of  a  blennorrhagic  diathesis  analogous 
to,  but  not  identical  with,  the  syphilitic  diathesis,  and 
of  an  acquired  diathesis  corresponding  to  an  individual 
predisposition,  which  individual  predisposition  Founder 
admits, 

Tixier,  who  has  Avritten  an  extended  essay  on  the  sub- 
ject, also  believes  in  a  blennorrhagic  diathesis. 

Bonnieres  asserts  that  arthropathy  and  blennorrhagia  are 


28T 

notMng  more  than  the  expression  of  the  same  vice — the 
rheumatic  diathesis. 

Thiry  believed  that  the  so-called  blennorrhagic  arthritis 
is  merely  coincident  with  urethritis,  without  being  related 
to  it  in  the  slightest  degree. 

It  has  been  noticed  that  individuals  suflEering  from  "  ure- 
thral rheumatism  "  are  often  affected  with  eczematous  and 
other  cutaneous  eruptions. 

Ample  experience  has  shown  that  simple  non-virulent 
urethritis  is  as  liable  to  be  accompanied  by  "  urethral  rheu- 
matism "  as  the  virulent  species. 

While  Fournier,  the  highest  authority  on  the  subject, 
believes  in  the  existence  of  a  "blennorrhagic  rheumatism," 
he  admits  that  rheumatism  arises  also  from  non-venereal 
urethral  phlegmasia,  and  for  that  reason  gave  it  the  name 
of  "urethral  rheumatism,"  which,  after  all,  is  no  better 
than  gonorrhoeal,  blennorrhagic,  or  genital  rheumatism,  and 
in  reality  means  simply  rheumatism  of  the  urethra. 

These  views,  the  outcome  of  one  hundred  years  of  dis- 
cussion of  the  question  of  rheumatism  occurring  among  in- 
dividuals suifering  from  genital  phlegmasia,  are  all  incon- 
clusive, for  they  fail  to  explain  the  true  nature  of  the  affec- 
tion, and  seem  to  relate  more  to  its  phenomena  than  its 
essence. 

Of  the  many  arguments  made  to  establish  a  distinctness 
of  "genital  rheumatism"  from  common  rheumatism,  not 
one  seems  to  adduce  evidence  sufficient  to  warrant  such 
specialization.  Nor  do  the  contrary  arguments  seem  better 
founded.     A  critical  examination  of  both  sides  of  the  ques- 


288 


tion  brings  into  bold  relief  tbeir  weak  as  well  as  tbeir  strong 
points.  Both  strive  to  prove  too  mucli  and  thereby  injure 
their  cause.  Those  who  wish  to  specialize  "  genital  rheu- 
matism "  make  urethritis  its  essential  cause,  and  assert  that 
it  has  few  if  any  of  the  characters  of  common  rheumatism, 
though  they  acknowledge  that  it  is  sometimes  acute,  the 
great  majority  of  cases  being  subacute,  and  often  chronic 
and  affecting  the  knee.  They  further  acknowledge  that  it 
afiects  parts  which  are  just  as  commonl}'"  involved  in  ordi- 
nary rheumatism,  and  some  of  the  contestants  even  point 
out  sequelae  which  belong  to  ordinary  rheumatism.  They 
thus  enumerate  the  parts  affected  in  "  genital  rheumatism," 
arthritis,  hydrarthrosis,  and  arthralgia  of  the  large  and 
small  joints,  bursitis,  sciatica,  myalgia,  ophthalmia,  and 
affections  of  the  heart,  of  the  membranes  of  the  brain, 
spinal  cord,  etc.  Those  who  take  the  contrary  side 
say  that  the  rheumatic  manifestations  are  merely  coinci- 
dent and  do  not  bear  the  slightest  relation  to  genital  phleg- 
masia. 

It  seems  that  the  extreme  views  of  both  contesting  sides 
should  be  rejected,  because  the  assertion  that  genital  phleg- 
masia is  the  essential  cause  of  the  rheumatism  is  not  proved, 
and  because  it  is  not  proved  that  the  rheumatism  bears  no 
relation  to  the  genital  phlegmasia. 

Is  it  not  likely  that  the  affection  is  ordinarily  a  subacute 
rheumatism,  excited  in  a  vulnerable  subject  by  the  genital 
phlegmasia,  just  as  it  might  be  excited  by  any  other  phleg- 
masia, and  that  it  therefore  does  bear  a  distinct  and  close 
relation  to  its  exciting  cause  ? 


289 

It  is  hoped  that  bio-chemists  and  patho-histologists 
will  re-examine  the  lactic-acid  and  other  questions,  and 
ere  long  enlighten  the  profession  respecting  the  essence 
of  what  is  called  rheumatism,  and  help  to  determine  if 
its  association  with  genital  phlegmasia  is  or  is  not  a  coin- 
cidence. 

Whatever  may  be  the  nature  of  the  ailment  commonly 
styled  "  gonorrhoea!  rheumatism,"  its  treatment  differs  little 
if  at  all  from  that  of  acute  or  that  of  subacute  rheumatism, 
19 


290 


XII. 

Chronic  Urethritis  ;   its  Nature,  Causes,  Physical 
Characters,  Diaqnosis,  and  Treatment. 

The  nature  and  treatment  of  clironic  urethritis  for  a 
long  time  greatly  perplexed  physicians,  because  the  several 
pathic  conditions  which  give  rise  to  persistent  urethral  dis- 
charges had  not  been  sufficiently  well  studied,  and  because 
the  characters  and  sources  of  the  discharges  were  not  ascer- 
tained. These  discharges  were  found  to  be  so  refractory  to 
treatment  that  many  empirical  methods  were  used  with  lit- 
tle or  no  effect.  It  would  be  a  waste  of  space  to  enumerate 
the  many  modes  of  treatment  that  have  been  employed  dur- 
ing the  past  century.  In  speaking  of  this  obstinacy  of 
chronic  urethral  discharges,  Ricord  said  to  his  disciples  : 
"After  having  tried  everything,  try  to  do  nothing";  for 
experience  had  taught  him  that  meddlesome  treatment  only 
served  to  aggravate  the  phlegmasia,  which  he  had  often 
observed  to  subside  soon  after  the  cessation  of  all  medi- 
cation. 

Although  some  light  was  thrown  by  Gubler  upon  the 
differential  diagnosis  of  some  of  the  lesions  that  cause 
chronic  urethral  discharges,  little  attention  was  paid  to  the 
teachings  of  his  excellent  essay  on  the  anatomy  and  phleg- 
masise  of  the  bulbo-urethral  glands,  which  show  that  when 
a  persistent  urethral  discharge  of  a  clear  and  very  viscid 
mucoid  substance  occurs,  its  source  is  surely  in  one  bulbo- 


291 

urethral  gland  or  in  both  glands,  but  that  when  this  viscid 
discharge  is  purulent  there  is  chronic  phlegmasia  of  the 
hulbo-urethral  gland  or  glands.  This  clearly  indicates  that 
all  urethral  discharges  are  not  necessarily  signs  of  chronic 
urethritis.  An  acute  urethritis  may  be  cured  and  leave  no 
other  trace  than  chronic  phlegmasia  of  a  bulbo-urethral 
gland  or  of  its  duct.  In  some  cases,  instead  of  bulbo-ure- 
thral adenitis,  chronic  cryptitis  is  consecutive  to  acute  ure- 
thritis ;  in  these  cases  the  discharge  is  very  little  viscid,  but 
has  the  odor  characteristic  of  the  mucous  secretion  of  the 
urethral  crypts.  In  other  cases  chronic  prostatitis  or  gone- 
cystitis  may  be  consecutive  to  the  acute  urethritis. 

Mercier,  who  made  a  careful  examination  of  the  ques- 
tion of  chronic  urethritis,  did  much  toward  disseminating 
correct  views  respecting  the  pathology  and  treatment  of  this 
phlegmasia. 

Next  came  the  labors  of  Desormeaux,  who  demonstrated, 
with  the  aid  of  the  urethroscope,  true  granular  urethritis  to 
be  the  most  common  cause  of  persistent  purulent  urethral 
discharge.  From  that  time  chronic  urethritis  has  been  very 
diligently  studied,  and  other  lesions  have  been  discovered 
which  give  rise  to  chronic  purulent  urethral  discharge,  and 
at  present  the  treatment  is  directed  to  the  cure  of  the  lesions 
that  have  been  so  well  specialized. 

Nature  of  Chronic  Urethritis. — Chronic  urethritis, 
attended  with  a  slight  muco-purulent  discharge  popularly 
named  gleet,  morning  drop,  military  drop,  etc.,  mav  be  a 
termination  of  any  of  the  acute  types  of  urethritis,  may  be- 


292 


gin  as  a  benign  urethritis,  tlie  first  stage  of  tlie  acute  types, 
or  may  be  developed  far  back  in  the  uretbra,  be  latent  to 
the  sufferer,  and  be  discovered  by  tbe  physician  only  by 
means  of  the  urethroscope  or  of  a  microscopical  examina- 
tion of  the  urine.  It  should  not  be  confounded  ■with  ure- 
thral blennorrhoea,  true  gleet.  The  difference  between  these 
two  pathic  conditions  is  worthy  of  note.  Chronic  urethritis 
is  a  phlegmasia  of  the  urethral  mucous  membrane  yielding 
a  muco-purulent  discharge,  whilst  blennorrhoea  is  the  result 
of  an  excessive  secretion  of  mucus  by  the  urethral  crypts  or 
by  the  bulbo-urethral  glands  without  the  intercurrence  of 
phlegTQasic  action,  though  it  may  sometimes  be  a  sequel  of 
phlegmasia.  Frequent  sexual  erethism  without  copulation 
not  infrequently  causes  a  persistent  blennorrhoea  arising 
from  excessive  secretion  of  the  urethral  crypts  and  bulbo- 
urethral glands,  the  urinary  meatus  being  constantly  moist 
with  mucus  or  with  the  very  viscid  secretion  of  the  bulbo- 
urethral glands  without  admixture  of  pus.  This  is  true 
gleet,  unconnected  with  phlegmasic  action. 

The  phenomenon,  chronic  urethral  discharge,  unless  right- 
ly interpreted,  is  likely  often  to  lead  astray  both  patient  and 
physician.  The  inexperienced  sometimes  look  upon  chronic 
urethral  discharge  as  always  an  indication  of  urethral  strict- 
ure or  of  some  sort  of  obstruction  of  the  canal.  A  little  re- 
flection is  sufficient  to  throw  doubt  upon  such  a  view,  if  only 
on  account  of  its  want  of  proper  qualification,  a  suitable 
qualification  being  to  substitute  often  for  always,  and  to  say 
that  chronic  urethral  discharge  is  often  a  sign  of  stricture,  or 
is  sometimes  one  of  the  early  symptoms  of  stricture.    Such  a 


293 

view  would  be  indisputable.  It  is  well  known  that  a  cbronic 
urethral  discharge  may  emanate  from  (1)  phlegmasia  of  the 
seminal  vesicles,  (2)  of  the  prostatic  follicles,  (3)  of  the 
bulbo-urethral  glands,  (4)  or  of  the  urethral  crypts,  as  well 
as  from  (5)  a  circumscribed  or  a  diffuse  chronic  phlegmasia 
of  the  urethral  mucous  membrane.  It  may  be  asked,  How 
are  these  several  discharges  to  be  distinguished  ?  The 
answer  is  as  follows  : 

1.  The  discharge  from  the  seminal  vesicles  contains 
sympexia  and  spermatozooids.  Either  distinguishes  it 
from  all  the  other  discharges,  even  though  it  be  mixed 
with  them. 

2.  The  discharge  from  the  prostatic  crypts  is  turbid, 
milky,  and  sometimes  contains  many  prostatic  sympexia  and 
is  very  slightly  viscous. 

3.  The  discharge  from  the  bulbo-urethral  glands  is 
known  by  its  extreme  viscidity  ;  normally  it  is  of  crystal- 
line clearness,  but  becomes  opaque  when  containing  pus. 

4.  The  discharge  from  the  urethral  crypts  is  known  by 
its  peculiar  odor,  which  it  imparts  to  semen  and  which  is 
called  the  seminal  odor. 

5.  The  discharge  from  a  veritable  chronic  urethritis  is 
muco-purulent  and  characterized  by  the  profusion  of  pus 
cells  it  contains. 

Chronic  urethral  discharge,  no  matter  what  may  be  its 
origin,  is  generally  a  source  of  much  unnecessary  anxiety  to 
the  patient,  who  thinks  himself  the  most  sorely  afflicted  of 
all  mortals,  and  is  almost  incessantly  watching  the  drop 
which  he  believes  is  forever  to  reappear.     Of  course  it  does 


294 


reappear  as  long  as  lie  continues  to  irritate  tlie  urethra  by 
"  milking  the  penis  "  to  find  the  drop  when  he  thinks  it  is 
too  tardy  in  showing  itself.  The  morbid  mind  of  the  pa- 
tient sees  in  this  drop  a  virulent  poison  with  which  he  is 
infected  and  which  he  is  liable  to  transfer  to  any  woman 
with  whom  he  has  sexual  relations,  and  he  has  a  vague  no- 
tion that  this  poison  may  cause  almost  any  disease.  A 
medical  friend  related  a  case  illustrating  the  ludicrous  de- 
gree to  which  is  sometimes  carried  the  idea  that  a  chronic 
urethral  discharge  from  the  man  is  liable  to  cause  grave  dis- 
ease in  the  wife.  The  patient  in  question  had  been  repeat- 
edly told  that  his  urethral  discharge,  consisting  of  clear  mu- 
cus, was  not  contagious,  but  he  always  doubted  the  cor- 
rectness of  the  doctor's  view.  However,  he  finally  married 
and  his  wife  soon  became  pregnant,  but  on  or  about  the 
fourth  month  the  abdomen  was  so  much  more  distended 
than  it  would  be  even  at  full  term  that  an  examination  was 
made  which  revealed  a  large  multilocular  ovarian  cyst  whose 
extirpation  necessitated  an  extended  median  incision.  The 
anxious  husband,  who  had  attributed  this  condition  to  infec- 
tion by  his  urethral  discharge,  watched  the  operation  with 
much  solicitude,  not  on  account  of  its  gravity  but  of  the 
fixed  idea  that  he  might  be  the  cause  of  the  disease.  When 
he  saw  the  enormous  tumor,  he  said  that  if  it  had  been  a 
small  lump  he  would  have  blamed  himself,  but  that  then 
he  could  not  believe  it  possible  for  such  a  little  drop  to 
produce  a  growth  of  this  size  in  the  short  space  of  four 
months. 

Nothing  is  too  absurd  for  the  conception  of  some  of  the 


295 

sufferers  from  chronic  urethral  discharges.  They  listen 
credulously  to  the  ignorant  and  mendacious  dicta  of  crafty 
and  rapacious  charlatans,  while  they  are  suspicious  of  hon- 
est physicians,  and  obstinately  discredit  rational  advice  and 
correct  views.  Many  change  their  medical  adviser  as  often 
as  they  do  their  erratic  notions  of  the  ailment  which,  owing 
to  their  own  perversity,  is  destined  never  to  be  well.  The 
difficulties  experienced  in  the  management  of  such  cases  are 
too  well  known  to  require  extended  commentary. 

The  ideas  to  be  imjDressed  upon  the  minds  of  patients 
suffering  from  chronic  urethral  discharges  are :  1,  That 
these  affections  are  not  contagious  ;  2,  that  virulent  urethri- 
tis is  generally  cured  within  six  weeks,  but  that  in  some 
instances  several  relapses  occur,  the  last  of  which  is  almost 
certain  to  be  followed  by  a  slight  but  persistent  muco-puru- 
lent  discharge,  liable  even  after  four,  five,  or  six  months  to 
increase  so  as  to  simulate  an  attack  of  acute  urethritis,  sub- 
siding, however,  in  four  or  five  days  to  the  former  few 
drops  ;  3,  that  not  only  is  this  chronic  urethritis  non-trans- 
missible from  the  man  to  the  woman,  but,  on  the  contrary, 
is  most  frequently  aggravated  by  coition,  even  with  a 
woman  whose  genitalia  are  sound  and  remain  so  after  the 
coitus ;  4,  that  the  frequently  reiterated  assertion  that  a 
man  who  has  once  had  virulent  urethritis  in  his  bachelor 
days,  and  marries  years  after  the  attack  of  urethritis,  trans- 
mits "  the  gonorrhoeal  virus "  to  his  wife,  is  without  the 
slightest  foundation  ;  5,  that  this  irrational  notion  arose 
from  belief  in  a  "  gonorrhceal  virus  similar  to  but  not  identi- 
cal with  the  syphilitic  virus  "  ;  and  6,  that  the  correct  view 


296 

is  that  vinilent  urethritis  is  a  local  affection,  and  does  not 
become  constitutional. 

The  chief  causes  of  the  persistency  of  urethritis 

ARE  : 

1.  Disregard  of  hygienic  precautions  during  acute  ure- 
thritis, or  after  its  apparent  cure.  Sexual  erethism  of  any 
kind,  in  thought  or  act,  improper  alimentation,  the  use,  even 
moderate,  of  alcoholic  or  fermented  beverages,  over  exer- 
cise, and  excesses  in  general,  all  aggravate  the  acute  type  of 
the  phlegmasia  or,  after  it  has  begun  to  decline,  cause  its 
recrudescence,  and  finally  the  persistence  of  the  stage  of 
decline  which  constitutes  chronic  urethritis. 

2.  Inappropriate  treatment  of  the  acute  types  of  urethri- 
tis— such  as  the  so-called  abortive  treatment  by  injections 
of  nitrate  of  silver  in  strong  solution,  or  of  strong  solutions 
of  any  sort,  by  the  abase  or  the  untimely  use  of  balsamics, 
antiphlogistics,  diluents,  and  baths — is  among  the  prominent 
factors  in  the  causation  of  chronic  urethritis. 

3.  Vulnerability  of  the  subject — that  is  to  say,  an  inor- 
dinate susceptibility  to  phlegmasia,  owing  to  the  hyper- 
lithuria  so  common  among  chronic  dyspeptics,  or  to  some 
diathetic  influence,  besides  a  constitution  naturally  feeble 
or  impaired  by  disease  or  debauch — may  be  added  to  the 
setical  factors  of  chronic  urethritis. 

4.  Continued  local  irritation  of  the  urethra  is  another 
potent  factor  in  the  maintenance  of  urethral  phlegmasia. 
This  irritation  may  arise  from  frequent  coition,  from  mas- 
turbation, from  the  existence  of  a  stricture,  from  congenital 


297 


stenosis  of  the  urinary  meatus,  from  vesical  stones,  chronic 
cystitis,  chronic  prostatitis,  gonecystitis,  haemorrhoids,  anal 
fissure,  eczema,  etc. 

5.  Excessive  general  and  local  treatment  of  the  acute 
types  of  urethritis  both  have  the  effect  of  prolonging  the 
phlegmasic  action — the  first  by  disturbing  the  digestive 
function  and  enfeebling  the  patient  and  lessening  his  pow- 
ers of  resistance,  besides  causing  grave  complications.  The 
large  doses  of  balsamics  long  continued  have  a  baneful  ef- 
fect upon  the  digestive  apparatus,  and  often  cause  distress- 
ing cutaneous  eruptions,  hyperlithuria,  and  even  nephritis. 
The  too  free  use  of  alkaline  diluents  also  tends  to  disturb 
digestion  and  otherwise  defeat  the  objects  for  which  these 
agents  may  be  intended.  The  second,  the  untimely  or  the 
excessive  use  of  urethral  injections,  is  a  prolific  cause  of  the 
persistence  of  urethritis  and  of  some  of  its  complications 
and  consequences.  The  too  common  tendency  to  treat  the 
urethra  as  if  it  were  not  a  part  of  the  human  body  is  owing 
chiefly  to  the  want  of  proper  interpretation  of  its  morbid 
phenomena.  It  is  over-distended,  divulsed,  or  cut  indis- 
criminately, simply  because  there  is  a  discharge,  and  with- 
out ascertaining  the  nature  of  this  flow.  The  idea  that  the 
discharge  is  a  sure  indication  of  the  existence  of  a  stricture 
is  enough  to  induce  the  unthinking  to  over-distend,  divulse, 
or  cut  the  urethra.  The  patient,  impressed  with  the  notion 
that  his  case  is  unparalleled  and  demands  extraordinary 
measures,  consents  to  any  proposed  mode  of  treatment, 
even  to  the  spilling  of  blood.  He  is  then  contented  until 
he  discovers  that  the  urethral  discharge  is  not  cured  by  the 


operation,    and   that   the    drop   still   obstinately   obtrudes 
itself. 

Physical  Characters. — The  alterations  of  structure  of 
the  mucous  membrane  in  chronic  urethritis  need  to  be  stud- 
ied during  life  by  means  of  the  bulbous  bougie  and  the  ure- 
throscope, as  well  as  by  dissection  after  death,  on  account 
of  their  variations  in  character,  site,  extent,  and  depth. 

In  some  cases  the  only  perceptible  lesion  is  congestion 
of  the  mucous  membrane.  This  congestion  is  generally  dif- 
fused over  a  space  of  two  or  three  inches,  involving  the 
bulbous,  membranous,  and  prostatic  regions.  It  rarely  in- 
volves the  whole  length  of  the  urethra.  Sometimes  the 
membrane  is  congested  in  small  patches  from  the  balanic 
region  backward. 

Most  frequently,  owing  to  excessive  epithelial  exfolia- 
tion in  the  acute  types  and  the  consequent  prolongation  of 
the  stage  of  decline,  another  condition  is  observable,  and 
that  is  a  granular  state  of  the  mucous  membrane,  designated 
as  caruncles  and  carnosities  by  writers  of  the  sixteenth  and 
seventeenth  centuries,  and  first  demonstrated  in  the  living 
by  Desormeaux  in  1864.  This  granular  state  is  in  reality 
an  effort  at  repair.  The  denudation  of  the  mucous  mem- 
brane is  more  complete  in  some  regions  of  the  urethra  than 
in  others,  notably  in  the  bulbous  portion  of  the  canal,  and 
there  is  a  constant  emigration  of  leucocytes,  some  of  which 
become  partly  organized,  forming  the  granulation  tissue, 
while  most  of  them  are  cast  away  as  pus.  Unless  modified 
by  treatment,  the  granular  state  continues  indefinitely,  and 


299 


beneath  the  granulations,  in  the  meshes  of  the  mucous 
membrane,  in  the  submucous  connective  tissue,  and  even  in 
the  spongy  substance,  is  an  exudate  which  in  time  becomes 
incompletely  organized,  sclerosed,  and  shriveled,  constituting 
stricture.  The  exudate  and  granulation  tissue  may  be  dis- 
tributed in  multiple  patches  or  may  encircle  the  urethra. 
Such  is  one  of  the  modes  of  development  of  urethral  strict- 
ure from  chronic  urethritis,  and  this  development  is  often 
the  work  of  five,  ten,  twenty,  or  thirty  years.  The  supple- 
ness of  the  urethra  is  impaired  wherever  there  are  granula- 
tions with  an  underlying  exudate.  The  bulbous  bougie  and 
the  urethroscope  reveal  both  conditions. 

Another  way  in  which  urethritis  is  perpetuated  is  when 
a  superacute  urethritis  has  caused  acute  submucous  ure- 
thritis. In  such  a  case  the  alteration  of  structure  is  much 
more  profound  and  rapid,  sclerosis,  shriveling,  and  strict- 
ure occurring  in  a  few  months  and  exciting  a  constant 
muco-purulent  discharge  which  is  liable  to  increase  in 
thickness  and  quantity  after  the  slightest  imprudence,  even 
to  the  simulation  of  acute  urethritis. 

A  noteworthy  circumstance  is  the  frequent  development 
of  a  very  mild  urethritis,  with  slight  muco-purulent  dis- 
charge, from  what  is  commonly  the  first  stage  of  the  acute 
types.  This  form  of  urethritis  has  some  of  the  characters 
of  chronic  phlegmasia  from  the  first,  it  is  attended  by  phe- 
nomena similar  to  those  of  chronic  urethritis  consequent 
upon  acute  urethritis,  and  is  as  persistent.  In  these  cases 
there  are  the  patches  of  granulation  tissue,  the  submucous 
exudate  perhaps  only  in  a  very  slight  degree,  and  in  point 


300 


of  fact  most  of  the  lesions  found  in  chronic  urethritis  that 
arises  from  the  acute  types ;  and  stricture  is  one  of  the 
sequelae  of  this  form  of  chronic  urethritis  as  much  as  it  is 
of  the  ordinary  chronic  type. 

When  unchecked,  chronic  urethritis  causes  alterations  of 
structure  in  the  urethral  mucous  crypts  and  glands  to  the 
extent  of  sometimes  destroying  them.  It  is  liable  also  to 
be  propagated  to  the  bulbo-urethral  glands,  to  the  prostate, 
to  the  vesico-urethral  region,  and  even  to  the  testicles. 
Long  neglected,  even  the  simplest  form  of  chronic  ure- 
thritis almost  inevitably  leads  to  stricture  of  the  canal  or  to 
contracture  of  the  vesical  neck. 

In  the  diagnosis  of  chronic  urethritis  it  should  be 
remembered  that  all  urethral  discharges  do  not  necessarily 
indicate  urethritis.  Thus  a  clear  glairy  discharge  emanates 
from  the  urethral'  crypts  without  phlegmasic  action,  and 
likewise  an  extremely  viscid  discharge  comes  from  the 
bulbo-urethral  glands.  A  purulent  discharge  may  come 
from  the  vesico-urethral  region,  from  the  prostate,  or  from 
the  seminal  vesicles.  The  true  basis  of  the  diagnosis  of 
chronic  urethritis  rests  upon  a  complete  history  of  the  case, 
gross  and  microscopical  inspection  of  the  discharge,  and  ex- 
ploration of  the  urethra  with  the  bulbous  bougie  or  with 
the  urethroscope. 

If  a  patient,  applying  for  treatment  on  account  of  a  per- 
sistent urethral  discharge,  confess  to  one  or  two  antecedent 
attacks  of  acute  urethritis,  it  is  fair  to  assume  his  present 
discharge  to  be  the  sequel  of  the  acute  urethritis,  even  if 


301 


this  attack  of  acute  urethritis  date  back  a  few  months  or 
several  years.  But  while  this  information  helps,  it  is  not 
sufficient  to  indicate  the  particular  form  and  site  of  the 
existing  chronic  urethritis.  The  other  aids  to  diagnosis, 
consisting  in  the  use  of  instruments  of  precision,  are  essen- 
tial to  accuracy.  The  first  of  these  aids  to  be  used  is  the 
bulbous  bougie.  A  No.  12  (English)  bulbous  bougie  is  or- 
dinarily of  convenient  size  for  the  purpose.  This  instru- 
ment is  gently  and  slowly  introduced  into  the  urethra  until 
the  patient  experiences  a  sense  of  tenderness  and  perhaps 
even  of  pain  at  a  particular  spot.  The  tender  spot  is  gen- 
erally a  patch  of  granulation  tissue  covered  with  a  layer  of 
pus.  The  bulb  is  then  carried  onward  about  half  an  inch 
beyond  the  tender  spot,  where  there  may  be  neither  tender- 
ness nor  pain,  left  in  position  for  a  minute,  and  slowly  with- 
drawn. If  the  base  of  the  bulb  is  coated  with  a  whitish 
substance,  this  should  at  once  be  subjected  to  microscopical 
examination.  If  it  proves  to  be  pus,  the  granular  nature  of 
the  tender  spot  may  be  considered  as  verified.  In  some 
cases  the  granulation  tissue  bleeds  freely  on  the  slightest 
provocation,  and  the  bulb  of  the  bougie  is  coated  with 
blood.  During  the  introduction  and  withdrawal  of  the 
bougie  a  delicate  touch  can  discern  a  certain  lack  of  sup- 
pleness of  the  urethra,  particularly  where  there  are  several 
tender  spots  close  together,  or  when  a  granular  space  with 
an  underlying  exudate  encircles  the  urethral  mucous  mem- 
brane. This  does  well  for  urethritis  anterior  to  the  bulbo- 
membranous  junction.  If  the  examination  is  negative,  all 
the  anterior  part  of  the  urethra  may  be  washed,  and  a  bulb 


302 


ous  bougie  carried  beyond  tbe  bulbo-membranous  junction 
into  tbe  prostatic  region  and  withdrawn  as  before.  A  coat- 
ing of  pus  upon  tbe  base  of  tbe  bulb  will  indicate  tbe  site 
of  tbe  granulations  and  source  of  tbe  discbarge,  or,  after 
washing  tbe  anterior  uretbra,  tbe  patient  is  asked  to  urinate 
into  two  separate  glass  vessels.  If  tbe  first  urine  contains 
pus  and  tbe  second  is  free  from  pus,  it  may  be  inferred 
tbat  tbe  pus  bas  come  from  tbe  membranous  or  prostatic 
region.  Tbe  urethroscope,  however,  brings  to  view  tbe 
granulations,  their  extent  and  their  exact  locality,  or  reveals 
simply  a  congested  state  of  the  raucous  membrane,  diffused 
or  in  patches. 

When  a  stricture  has  already  formed,  there  is  almost 
always  behind  this  stricture  a  granular  state  of  the  mu- 
cous membrane,  which  yields  a  more  or  less  abundant 
purulent  discharge.  This  is  perhaps  what  has  led  some  ob- 
servers to  consider  tbat  a  urethral  discbarge  is  tbe  infallible 
sign  of  stricture.  In  point  of  fact,  the  discbarge  had  long- 
preceded  the  stricture  and  was  one  of  the  phenomena  of 
tbe  pathic  state  that  caused  tbe  stricture — i.  e.,  granular 
urethritis  with  an  underlying  exudate,  the  urine,  partly 
dammed,  irritating  the  mucous  membrane  immediately  be- 
hind the  stricture  and  thus  perpetuating  tbe  discbarge. 
Tbe  cure  of  tbe  stricture  is  followed  by  the  disappearance 
of  tbe  granulation  tissue  and  of  tbe  consequent  discharge. 

To  TREAT  CHRONIC  URETHRITIS  rationally  and  success- 
fully it  is  essential  to  distinguish  the  several  chronic  urethral 
discharges,  to  ascertain  the  cause  of  the  phlegmasia,  its  du- 


303 


ration,  tlie  kind  of  treatment  to  which  it  may  already  have 
been  subjected,  and  the  physical  condition,  habits,  and  en- 
vironment of  each  individual — in  other  words,  to  make  a 
correct  diagnosis.  The  mere  gleet  of  clear  urethral  mucus 
requires  no  local  treatment.  It  is  particularly  this  gleet 
that  is  so  excessively  treated  and  by  so  many  different  cruel 
methods.  The  more  it  is  treated  the  worse  it  becomes,  and 
finally  the  heroic  treatment  leads  to  an  almost  incurable 
chronic  purulent  discharge.  Wise  hygienic  management 
and  avoidance  of  certain  factors  in  the  causation  of  over- 
secretion  of  mucus,  such  as  sexual  erethism,  suffice  to  re- 
store the  urethral  glands  to  their  normal  state. 

The  management  of  sufferers  from  chronic  urethritis  is 
attended  with  many  difficulties,  partly  owing  to  the  moral 
as  well  as  the  physical  condition  of  the  patient,  partly  in- 
herent to  the  affection  itself.  Their  treatment  should  there- 
fore be  moral,  general,  and  local.  ISTothing  will  satisfy  the 
patient  except  the  cessation  of  the  discharge.  To  bring 
this  about  is  the  chief  indication,  so  far  as  the  view  of  the 
patient  is  concerned,  but  to  the  physician  the  indication  is 
not  only  to  cure  the  local  phlegmasia  which  gives  rise  to 
the  discharge,  but  to  prevent  the  formation  of  stricture. 

The  character  of  the  moral  management  has  already  been 
hinted  at  in  the  beginning  of  this  conference.  In  addition, 
it  may  be  said  that  the  physician  should  gain  the  absolute 
confidence  and  insure  the  co-operation  of  his  patient,  with- 
out which  all  treatment  would  be  in  vain.  He  should  dis- 
suade him  from  concentrating  his  thoughts  upon  and  from 
continuing  to  magnify  his  infirmity,  and,  above  all,  should 


304 


break  Ms  habit  of  stripping,  squeezing,  and  "  milking  "  tbe 
penis  to  bring  to  view  the  too  tardy  drop,  for  tbis  alone  is 
sufficient  to  perpetuate  the  discbarge  wbicb  migbt  other- 
wise disappear  even  without  local  treatment. 

The  general  treatment  is  directed  to  the  improvement  of 
the  physical  condition  of  the  patient,  to  place  him  in  the 
most  favorable  hygienic  condition,  to  combat  hyperlithuria, 
and  to  strive  to  remove  some  of  the  causes  tending  to  per- 
petuate the  phlegmasia.  The  use  of  balsamics  in  chronic 
urethritis  is  apt  to  be  worse  than  useless,  for  these  drugs 
almost  invariably  disturb  digestion  even  in  a  short  time. 
An  exception  may  be  made  in  favor  of  the  oil  of  gaultheria, 
which  sometimes  acts  as  a  very  effective  sterilizer  of  the 
urine  in  chronic  as  well  as  in  acute  urethritis ;  nevertheless 
this  agent  should  be  used  with  prudence  and  in  doses  of 
not  more  than  five  minims  thrice  daily.  Another  valuable 
sterilizer  of  the  urine  is  salol  used  in  moderate  doses.  Al- 
kaline mineral  waters  should  be  given  sparingly  and  for  not 
more  than  eight  or  ten  consecutive  days. 

The  local  treat7nent  of  chronic  urethritis  varies  with  the 
site  of  the  urethritis,  the  particular  alteration  of  structure, 
and  the  complications. 

In  case  of  simple  chronic  urethritis,  in  which  there  are 
no  granulations  or  submucous  exudate,  but  only  congestion 
of  the  mucous  membrane,  diffuse  or  in  patches,  particularly 
when  this  congestion  is  limited  to  the  "  antebulbar"  region, 
mild  astringent  irrigations  are  indicated.  It  is  wise,  however, 
to  keep  the  patient  under  close  observation  for  a  week  or 
ten  days,  and  during  that  time  to  make  no  local  applications 


305 

whatever,  for  the  general  treatment  may  suffice  to  cure  the 
urethritis.  If  then  the  discharge  persists,  the  urethra,  for 
the  first  five  or  six  days,  should  be  irrigated,  only  once 
daily,  with  ten  or  twelve  ounces  of  a  solution  of  boric  acid 
or  biborate  of  sodium,  five  grains  to  the  ounce.  Afterward 
chloride  of  zinc  should  be  substituted,  but  the  zinc  salt  so- 
lution should  not  exceed  half  a  grain  to  the  ounce.  The 
quantity  of  fluid  used  for  each  irrigation  should  be  about 
ten  ounces.  As  a  general  rule,  this  form  of  chronic  ure- 
thritis yields  rapidly  to  the  irrigations,  and  in  the  course  of 
a  few  weeks  is  well. 

In  case  of  chronic  cryptitis,  the  "  antebulbar "  irriga- 
tions of  boric  acid  and  afterward  of  zinc  chloride  should  be 
made  from  before  backward,  so  as  to  wash  away  from  the 
crypts  the  accumulated  muco-pus. 

Chronic  urethritis  toith  granulations  demands  a  some- 
what different  treatment,  although  in  the  beginning  the 
irrigations  with  boric-acid  solution  should  be  used  for 
several  days.  If  the  granular  urethritis  be  "antebulbar," 
the  best  modifier  that  can  be  used  is  the  nitrate  of  silver  in 
solution  of  half  a  grain  to  the  ounce,  one  grain  to  the 
ounce,  and  seldom  increased  to  two  grains  to  the  ounce. 
The  amount  of  fluid  should  not  be  less  than  six  ounces, 
but  should  be  used  only  once  every  four  or  five  days. 

In  granular  urethritis  of  the  membranous  and  prostatic 

regions,  particularly  in  case  of  coexisting  chronic  gonecys- 

titis,  the    strength  of   the    nitrate-of-silver    solution   may, 

with  advantage,  be  increased  to  three,  four,  or  even  five 

grains  to  the  ounce,  and  three  or  four  ounces  only  need  be 
20 


306 


used  every  four  or  five  days.  Tlie  bladder  should  contain 
a  few  ounces  of  urine  in  order  to  insure  the  quick  decom- 
position of  the  silver  salt.  It  is  well  known  that  when 
fluid  is  thrown  slowly  and  without  undue  force  through  a 
catheter  as  far  as  the  bulbo-membranous  junction,  it  re- 
turns and  escapes  at  the  meatus,  but  that  when  the  catheter 
is  passed  into  the  membranous  region  none  of  the  fluid 
escapes  externally,  but  all  of  it  enters  the  bladder.  Mer- 
cier  pointed  this  out  many  years  ago,  and  the  experiences  of 
otiuer  physicians  have  confirmed  the  view.  Two  days  after 
each  urethral  irrigation  a  steel  sound  of  moderate  size 
should  be  cautiously  introduced  as  far  as  the  bladder. 
Too  frequent  catheterism  or  excessive  dilatation  only  serves 
to  defeat  the  objects  sought  to  be  attained.  The  sound 
should  be  carefully  withdrawn  in  a  minute's  time,  the  pur- 
poses of  its  introduction  being  to  make  pressure  upon  the 
granulations,  to  slightly  stretch  the  urethra  at  the  seat  of 
disease,  and  to  restore  the  suppleness  of  the  canal. 

There  are  cases  of  granular  urethritis  that  obstinately 
resist  this  treatment.  These  cases  require  direct  applica- 
tions to  the  granulation  tissue,  to  accomplish  which  the  use 
of  the  urethroscope  becomes  necessary.  The  granulations 
thus  brought  to  view  are  penciled  with  a  solution  of  nitrate 
of  silver  (ten,  twenty,  or  thirty  grains  to  the  ounce)  every 
four  or  five  days  until  they  disappear.  Sulphate  of  copper 
and  other  substances  have  been  used  for  the  purpose,  but 
are  all  inferior  to  the  nitrate  of  silver. 

Strong  solutions  are  not  well  borne,  are  even  mischiev- 
ous, and  therefore  contra-indicated,  in  chronic  urethritis 


307 


anterior  to  the  bulbo-membranous  junction,  but  are  well 
tolerated  and  effective  when  applied  to  the  membranous 
and  prostatic  regions,  where  may  be  used  with  advantage 
the  method  of  Guyon  by  the  instillation  of  ten,  twenty,  or 
thirty  minims  of  nitrate-of- silver  solution  (ten,  twenty,  or 
thirty  grains  to  the  ounce),  to  be  in  a  minute  washed  into 
the  bladder  by  a  current  of  water,  and  repeating  the  process 
every  three  or  four  days.  From  Guyon's  method  good 
results  have  been  obtained  in  otherwise  intractable  cases, 
particularly  those  complicated  with  chronic  prostatitis, 
gonecystitis,  or  trachelocystitis. 

Counter -irritation. — In  certain  cases  of  chronic  urethri- 
tis involving  the  perineal  or  prostatic,  or  both,  regions  of 
the  urethra,  particularly  those  attended  with  dull  pain  and 
a  constant  teasing  sense  of  irritation  in  the  parts,  counter- 
irritation  of  the  perinaeum  by  means  of  vesicating  collodion 
is  often  of  much  service,  and  should  be  used  every  three 
or  four  days  for  several  weeks.  The  vesicating  collodion 
should  be  applied  with  a  camel's-hair  brush  on  one  side  of 
the  perineal  raphe,  over  a  surface  of  half  an  inch  by  an  inch 
and  a  half,  and  the  perinseum  covered  with  a  layer  of  ab- 
sorbent cotton,  in  order  that  the  blistered  skin  may  speedily 
heal.  In  three  days  the  blistering  process  is  repeated  on 
the  opposite  side  of  the  raphe,  and  so  on  every  three  or 
four  days  until  the  desired  effect  is  accomplished. 

When  chronic  urethritis  is  kept  up  by  stenosis  of  the  mea- 
tus urinarius,  or  of  any  other  part  of  the  urethral  canal,  it 
can  be  cured  only  after  the  removal  of  the  obstruction  to 
urination,  in  the  first  case  by  incision,  in  the  second  case  by 


308 

dilatation,  divulsion,  or  incision,  according  to  tlie  character 
and  particular  site  of  the  stricture. 

In  chronic  urethritis  due  to  urethral  tuberculosis,  no  treat- 
ment other  than  the  palliative  is  of  any  avail.  The  dis- 
charge increases  in  quantity  from  day  to  day,  in  it  swarm 
the  characteristic  tubercle  bacilli,  and  the  patient  soon  suc- 
cumbs to  the  inroads  of  general  tuberculosis.  A  specimen 
exhibited  showed  tuberculosis  extending  from  the  meatus 
urinarius  to  the  bulbo-urethral  glands,  spermatic  canals, 
seminal  vesicles,  prostate,  bladder,  peritonseum,  and  right 
ureter  and  kidney.  The  left  kidney  had  undergone  com- 
pensatory enlargement  and  was  not  tuberculous.  Both 
testicles  had  been  extirpated,  on  account  of  tuberculosis,  six  . 
months  before  the  death  of  the  patient.  The  specimen  was 
a  particularly  good  illustration  of  ascending  tuberculosis 
of  the  urinary  apparatus.  There  had  been  for  several 
weeks  a  thick  urethral  discharge,  in  which  great  numbers 
of  tubercle  bacilli  were  detected.  Several  other  specimens 
were  exhibited  to  illustrate  descending  tuberculosis  of  the 
urinary  apparatus.  The  disease,  having  begun  in  the  lungs, 
secondarily  affected  the  kidneys,  descended  to  the  bladder 
and  urethra,  and  caused  an  obstinate  purulent  discharge. 


309 


ADDENDUM. 

Retention  of  Urine  from  Prostatic  Obstruction  in 
Elderly  Men  :  Its  Nature,  Diagnosis,  and  Man- 
agement. 

The  following  paper,  read  to  the  ]N'ew  York  State  Medi- 
cal Association  in  October,  1890,  is  here  inserted  as  a  sup- 
plement to  that  part  of  the  conference  on  cystitis  which  re- 
lates to  the  nature  and  management  of  retention  of  urine, 
because  it  gives  more  explicit  directions  in  the  use  of  the 
needed  instruments. 

While  urethro-vesical  obstruction  occurs  in  young  and 
middle-aged  men  from  bladder  and  prostate  stones,  from 
acute  prostatitis,  from  contracture  of  the  vesical  neck  due 
to  the  extension  of  chronic  urethritis,  or  from  malignant 
disease  of  the  prostate,  it  should  not  be  confounded  with 
the  gradual  and  slow  process  of  prostatic  obstruction  which 
rarely  begins  to  impede  urination  before  the  age  of  fifty- 
five  and  is  as  rarely  known  to  begin  after  the  age  of  sev- 
enty. 

Causes  of  Impediment  to  Urination. — To  the  ques- 
tion. What  is  it  that  causes  this  impediment  to  urination  in 
elderly  men  ?  a  common  but  incomplete  answer  is  enlarge- 
ment of  the  prostate.  This  answer  is  incomplete  because 
of  its  failure  to  specify  the  kind  of  enlargement,  for  it  is 
known  that  elongation  and  also  uniform  general  enlarge- 


310 


ment  of  the  prostate  do  not  obstruct  the  urethro-vesical 
orifice  or  impede  urination.  Very  large  prostates  have 
been  discovered  after  death  in  elderly  men  who  had  never 
suffered  the  least  inconvenience  in  urinating  and  whose 
bladders  were  in  a  normal  condition.  On  the  other  hand, 
small  prostates — i.  e.,  of  even  less  bulk  than  natural,  with 
only  moderate  increase  of  the  lower  isthmus — sufficiently 
obstruct  the  urethro-vesical  orifice  to  give  rise  to  stagna- 
tion of  urine,  cystitis,  and  even  to  complete  retention  of 
urine. 

It  is  then  only  when  the  prostate  is  unequally  enlarged 
that  it  interferes  with  urination,  and  to  this  even  there  are 
exceptions,  for  multiple  tumors  at  its  base  sometimes  cause 
true  incontinence  of  urine,  as  do  other  forms  of  prostatic 
enlargement  which  prevent  the  closure  of  the  urethro-vesi- 
cal orifice  and  allow  the  urine  to  flow  constantly  from  the 
bladder  as  fast  as  it  trickles  out  of  the  ureters.  In  connec- 
tion with  this  subject  it  may  be  said  that  enlargement  of 
the  prostate,  conveying  as  it  does  only  a  general  notion  that 
the  organ  is  in  an  abnormal  state,  needs  to  be  specified,  and 
it  can  ordinarily  in  some  measure  be  specified  after  due  ob- 
servation of  its  immediate  effects ;  for  instance,  an  elderly 
man  from  whom  normal  urine  is  constantly  dribbling  and 
who  suffers  no  other  inconvenience  presumably  has  true  in- 
continence of  urine  due  to  some  form  of  enlargement  of 
the  prostate  which  keeps  open  the  urethro-vesical  orifice, 
while  another  elderly  man  from  whom  foetid  purulent  urine 
is  constantly  dribbling  presumably  has  chronic  retention  of 
urine  due  to  urethral  or  to  urethro-vesical  obstruction  from 


311 


some  one  of  the  forms  of  prostatic  enlargement  specified 
below,  urethral  stricture  or  the  impaction  of  a  calculus  in 
the  urethra  having  been  excluded. 

Of  the  several  forms  of  unequal  enlargement  of  the  pros- 
tate which  obstruct  the  urethro- vesical  orifice  the  following 
only  need  now  be  named :  (1)  General  enlargement  with 
excessive  development  of  the  posterior  third  of  the  lower 
isthmus,  called  supramontanal  portion  by  Mercier  and 
third  lobe  by  Home ;  (2)  enlargement  of  the  posterior  third 
of  the  lower  isthmus  without  apparent  increase  in  the  rest 
of  the  prostate,  sometimes  called  centric  enlargement ;  (3) 
enlargement  of  one  lobe  which  encroaches  upon  the  oppo- 
site lobe  and  obstructs  the  prostatic  urethra  ;  (4)  unequal 
enlargement  of  both  lobes,  rendering  the  prostatic  urethra 
tortuous  and  obstructing  it ;  (5)  multiple  intra-urethral  tu- 
mors ;  (6)  intra-vesical  enlargement  of  one  lobe.  Such  are 
the  principal  forms  of  prostatic  enlargement  that  impede 
urination. 

These  alterations  of  structure  differ  somewhat  in  their 
component  elements.  The  majority  of  cases  are  diffuse  leio- 
myomata,  with  a  very  small  quantity  of  fibrous  tissue  ac- 
companying the  blood-vessels,  and  ectasia  of  the  prostatic 
crypts,  the  sympexia  of  the  crypts  often  dying  and  becom- 
ing coated  with  phosphate  of  calcium,  and  consequently  in- 
creasing considerably  in  volume.  They  are  those  prostates 
which  Are  softer  than  normal  and  which  attain  the  2'reatest 
size.  In  some  cases  there  are  multiple  circumscribed  leio- 
myomata.  Other  cases  are  of  diffuse  and  circumscribed 
inomata.     They  are  the  small,  hard  prostates  which  some- 


312 

times  contain  retention  epithelial  cysts.  Adenomata  are 
not  so  frequently  found  as  are  tlie  myomata  and  inomata, 
and  are  circumscribed. 

The  first  effect  of  urethral  or  of  urethro-vesical  obstruc- 
tion is  stagnation  of  urine  in  the  bladder.  The  stagnant 
urine,  even  a  few  drachms,  soon  decomposes,  and,  acting  as 
an  irritant  foreign  body,  gives  rise  to  cystitis.  The  in- 
flamed bladder  then  makes  vigorous  but  vain  efforts  to  ex- 
pel this  offending  urine,  in  consequence  of  which  its  mus- 
cular coat  increases  in  thickness.  In  certain  cases  the 
larger  part  of  the  stagnant  urine  is  expelled,  but  the  small 
quantity  which  remains  is  sufficient  to  induce  such  frequent 
spasmodic  contractions  of  the  bladder  that  the  capacity  of 
this  organ  gradually  decreases  until  it  is  reduced  to  only 
two  or  three  ounces.  In  other  cases  the  bladder  is  dilated 
and  capable  of  containing  a  quart,  or  even  several  quarts,  of 
stale  urine.  In  either  class  of  cases,  unless  artificial  relief 
be  promptly  obtained,  the  consequences  are  of  the  gravest 
order.  The  urine,  thus  dammed  up,  leads  to  dilatation  of 
the  ureters,  ureteritis,  pyelitis,  nephritis,  and  death. 

It  may  be  asked,  Is  it  possible  to  make  a  reasonably  ac- 
curate diagnosis  of  these  several  kinds  of  prostatic  obstruc- 
tion ?_  Yes,  at  least  in  four  of  the  six  just  enumerated,  and 
it  is  of  no  little  practical  consequence  that  they  be  differ- 
enced, for  some  of  them  require  modifications  in  their  sur- 
gical management. 

The  early  manifestations  of  prostatic  enlargement  do  not 
always  cause  anxiety  and  are  often  overlooked.  The  pa- 
tient, having  perhaps  only  vague  notions  of  his  condition, 


313 

generally  misinterprets  the  gradually  increasing  frequency 
of  the  calls  to  urination,  does  not  perceive  that  his  urine  is 
slimy,  pays  little  attention  to  the  slight  sensation  of  scald- 
ing during  urination,  is  not  aware  of  the  significance  of  the 
changes  in  the  mode  of  propulsion  of  the  urine,  notably  the 
vertical  direction  of  the  jet,  fails  to  notice  the  diminished 
size  of  the  stream  vphose  sudden  cessation  induces  him  to 
think  that  the  act  of  urination  is  accomplished,  when,  to 
his  surprise,  more  urine  is  expelled  drop  by  drop,  to  be 
succeeded  by  the  former  perpendicular  stream  and  again  by 
the  drops,  and  does  not  solicit  the  advice  of  his  physician 
until  all  these  symptoms  are  greatly  intensified  or  until  he 
is  already  distressed  by  complete  retention  of  urine. 

Diagnosis. — Of  the  several  steps  in  the  diagnosis  of 
abnormal  urination  and  retention  of  urine  due  to  prostatic 
enlargement,  chiefly  the  following  are  employed  : 

The  history  of  the  patient's  prior  ailments,  of  his  actual 
infirmity,  and  of  his  habits  of  life,  having  been  obtained, 
an  inspection  of  his  general  condition  is  made.  His  mode 
of  urinating,  if  he  can  urinate,  is  noted,  and  his  urine  is 
duly  examined.     Then  follows  physical  exploration. 

The  first  step  in  this  exploration  is  palpation,  then  per- 
cussion of  the  hypogastric  region.  If  there  is  no  tumefac- 
tion, if  percussion  is  clear,  it  will  be  inferred  that  the  blad- 
der is  empty  or  nearly  so ;  and  if  at  the  same  time  it  is 
noticed  that  normal  urine  is  constantly  flowing,  it  will  be 
fair  to  infer  that  there  is  incontinence  rather  than  retention 
of  urine,  although  the  involuntary  flow  of  urine  indicates 


314 

oftener  its  retention  than  its  incontinence ;  but  if  there  is  a 
rounded,  tense,  and  painful  tumor,  dull  or  flat  under  per- 
cussion, and  with  this  a  constant  desire  to  urinate,  the  in- 
ference will  be  that  there  is  acute  retention  of  urine.  If, 
however,  there  happens  to  be  a  diffuse,  slack  swelling  with 
fluctuation,  also  flatness  under  percussion,  a  dull  instead  of 
an  acute  pain,  and  no  urgent  desire  to  urinate,  but  slobber- 
ing of  urine,  the  existence  of  chronic  retention  of  urine  will 
be  inferred. 

It  is  proper  to  state  that,  while  percussion  possesses 
some  value  in  the  diagnosis  of  retention  of  urine,  it  is  not 
to  be  absolutely  depended  upon.  For  example,  flatness  on 
percussion  does  not  necessarily  indicate  the  presence  of 
urine  in  the  bladder,  for,  in  the  hypogastric  region,  flatness 
may  be  owing  to  a  solid  tumor  in  front  of  the  bladder. 
Circumscribed  flatness  and  fluctuation  may  indicate  a  pel- 
vic abscess  as  well  as  stagnation  of  urine  in  the  bladder, 
with  more  or  less  distention.  Resonance  on  percussion 
does  not  indicate  absence  of  retention  of  urine,  for  such 
resonance  may  be  owing  to  the  presence  of  knuckles  of 
small  intestine  between  a  distended  bladder  and  the  ante- 
rior abdominal  parietes. 

The  second  step  in  physical  exploration  consists  in  mak- 
ing a  digital  examination  of  the  prostate  through  the  rec- 
tum, by  which  some  idea  may  be  formed  of  the  size  and 
consistence  of  the  organ.  As  a  general  rule,  hard  prostates 
are  little  if  at  all  enlarged,  while  soft  prostates  are  large 
and  sometimes  attain  enormous  dimensions.  By  this  same 
digital  examination,  the  form  as  well  as  the  size  of  the 


315 

prostate  is  estimated.  It  may  be  simply  elongated ;  one  of 
its  lateral  lobes  may  be  larger  tban  the  other ;  it  may  be 
uniformly  enlarged ;  it  may  be  nodulated,  and  this  suggests 
the  existence  of  multiple  tumors ;  or  it  may  not  be  larger 
than  natural,  but  its  apex  may  be  rounded  instead  of  being 
insensibly  lost  in  the  membranous  region  of  the  urethra. 
These  are  the  principal  circumstances  to  be  noted  from  a 
rectal  exploration. 

The  third  step  in  physical  exploration  consists  in  ascer- 
taining the  particular  kind  of  prostatic  enlargement  which 
affects  urination.  The  exploration  is  made  by  introducing 
certain  metallic  instruments  through  the  urethra  into  the 
bladder.  This  method  was  suggested  and  practiced  by 
Mercier  many  years  ago,  and  is  as  follows  :  A  rectangular, 
short-beaked  metallic  sound  (Fig.  1)  or  catheter  is  slowly 


Fig.  1. — Mercier's  rectangular  sound. 

introduced  until  it  reaches  the  prostatic  region  of  the  ure- 
thra. If  then  the  handle  turns  to  the  right  of  the  patient, 
it  is  because  the  point  of  the  instrument  has  been  deflected 
by  an  intra-urethral  projection  of  the  left  lobe  of  the  pros- 
tate, and  vice  versa.  If  first  to  the  right  and  then  to  the 
left  half  an  inch  or  thereabouts  farther  back,  it  is  because 
the  point  of  the  instrument  is  deflected  first  by  a  projection 
of  the  left  and  then  by  a  projection  of  the  right  lobe  of  the 


316 


prostate,  showing  unequal  enlargement  of  both  lobes.  If 
the  sound  meets  no  impediment  imtil  it  has  nearly  reached 
the  bladder,  and  then  its  blunt  heel  encounters  an  obstacle, 
it  is  because  there  is  enlargement  of  the  posterior  third  of 
the  lower  isthmus  (supramontanal  portion,  third  lobe).  By 
moderately  depressing  its  handle  and  gently  pushing  the 
sound  onward,  it  enters  the  bladder.  Its  beak  is  then  re- 
versed, and  turned  to  the  right  and  to  the  left  in  order  to 
form  some  idea  of  the  general  character  of  the  obstacle,  if 
there  be  intravesical  projection. 

But  for  greater  precision  the  cysto-pylometer  (Figs.  2 
and  3)  may  be  used.  By  means  of  this  simple  instrument 
the  thickness  of  the  obstacle  can  be  accurately  measured, 
and  it  can  be  ascertained  if  this  consist  of  a  crescentic  val- 
vule, of  a  "  bar,"  or  of  a  sessile  or  a  pedunculated  tumor. 

Fig.  2  represents  the  first  cysto-pylometer  devised  by 
the  author.  It  is  so  constructed  that  the  vesical  extremity 
of  the  male  blade  can  easily  override  any  urethro-vesical 
barrier  without  giving  pain  to  the  patient.  This  construc- 
tion of  the  jaw  of  the  male  blade  rendering  the  prehensile 
part  a  trifle  too  short,  a  new  pylometer  (Fig.  3)  with  the 
male  prehensile  part  one  third  longer  was  lately  contrived 
with  the  view  of  remedying  the  defect  of  the  first  instru- 
ment, but  in  this  new  pylometer  the  inclination  of  the  jaw 
is  so  abrupt  that  it  is  necessary  to  observe  the  greatest  care 
in  opening  the  jaw  of  the  instrument  to  carry  the  male  part 
over  a  urethro-vesical  barrier. 

The  several  forms  of  prostatic  enlargement  already  in- 
dicated give  rise  to  acute  and  to  chronic  retention  of  urine. 


317 


By  acute  retention  of  urine  is  meant  a  sudden  hinderance 
to  the  expulsion  of  urine  from  the  bladder.  It  is  char- 
acterized by  great  pain  in,  and  an  almost  intolerable  sense 


i 


Fig.  2.— The  author's  first 
cysto-pylometer. 


Fig.  3.— The  author's  second 
cysto-pylometer. 


818 


of  distention  of,  the  bladder ;  by  a  scalding  sensation  in  tbe 
urethra ;  and  by  a  constant  desire  to  urinate  which  seems 
incessantly  on  the  point  of  without  being  gratified. 

Acute  retention  of  urine  occurs  as  well  among  elderly 
men  with  incontinence  as  among  those  who  have  no  hin- 
derance  to  normal  urination,  or  only  a  very  slight  impedi- 
ment— i.  e.,  the  beginning  of  prostatic  obstruction. 

The  mechanism  of  acute  retention  of  urine  is  as  follows  : 
After  exposure  to  cold,  venereal  excess,  or  a  debauch,  the 
pelvic  vessels  sometimes  become  so  gorged  with  blood  that 
the  prostate  swells,  principally  in  the  direction  of  the 
urethra  and  ure thro- vesical  orifice,  to  the  extent  of  occlud- 
ing the  passage.  This  sudden  engorgement  is  soon  followed 
by  exudations  which  do  not  always  entirely  disappear. 
Resolution  is  occasionally  very  slow,  and  even  fails  ;  the 
swollen  prostate  is  then  little,  if  at  all,  diminished,  and 
acute  retention  may  thus  pass  into  chronic  retention  of 
urine. 

Acute  retention  of  urine  is  ordinarily  preceded  by  dys- 
uria  for  an  hour  or  two.  Urination  is  unduly  frequent, 
irregular,  scanty,  and  accompanied  with  scalding  pain  in 
the  whole  urethra  until  strangury  occurs  ;  then  urine  mixed 
with  mucus  and  blood  escapes  only  in  drops  at  each  spas- 
modic contraction  of  the  bladder.  Finally,  a  few  hours 
after  the  exposure  or  debauch,  comes  ischuria.  The  patient 
is  now  unable  to  discharge  a  single  drop  of  urine  and  is 
tormented  with  violent  straining,  which  favors  the  escape 
of  faecal  matter  and  even  causes  prolapse  of  the  rectum. 
The  passage  being  entirely  occluded,  the  urine  accumulates 


319 


from  hour  to  hour  until  the  bladder  is  greatly  overdis- 
tended  and  loses  its  power  of  contracting,  generally  for  a 
time  only,  sometimes  indetiuitely.  At  the  expiration  of 
the  first  day  the  suifering  is  still  very  great,  the  patient  be- 
comes more  restless,  feverish,  and  thirsty ;  his  face  is  con- 
gested from  the  constant  straining,  his  skin  is  dry,  and  his 
intestines  are  distended  with  gas.  On  the  second  day  the 
pain  extends  to  the  lumbar  regions,  and  the  dryness  of  the 
skin  is  succeeded  by  profuse  perspiration  having  a  urinous 
odor.  The  urine  then  begins  to  dribble,  and  this  is  delu- 
sive to  the  patient  and  to  his  family,  who  imagine  that 
spontaneous  relief  has  come,  when  in  truth  the  urine  is  still 
accumulating  in  the  bladder,  a  little  only  slobbering  out 
from  overflow.  The  consequence  of  this  misinterpretation 
of  a  symptom  is  failure  to  invoke  medical  aid  uniil  it  is 
deemed  proper  to  repress  what  is  wrongly  believed  to  be  a 
superabundant  flow  of  urine.  Meanwhile  the  patient  lapses 
into  a  muttering  delirium,  his  utterances  being  obscured 
partly  by  the  extreme  dryness  of  his  tongue  and  mouth. 
The  secretion  of  urine  is  now  lessened  (oliguria),  and  may 
soon  be  abolished  (anuria),  although  the  bladder  is  dis- 
tended to  the  extent  of  four  or  five  pints.  In  some  cases 
the  physician  is  not  summoned  until  many  nauseous,  use- 
less, and  often  hurtful  nostrums  and  diuretics  have  been 
administered. 

In  the  managemext  of  acute  retextiox  of  urixe,  to 
temporize  or  to  rely  solely  upon  the  use  of  medicaments  in 
any  case  is  to  place  the  life  of  the  patient  in  great  jeopardy. 


320 


Having  informed  himself  of  the  circumstances  connected 
with  the  case  and  having  made  a  preliminary  examination, 
the  physician  selects  the  form  of  catheter  best  suited  and 
forthwith  introduces  it,  allowing  the  urine  to  flow  very 
slowly,  and  every  few  seconds  stopping  up  the  distal  end 
of  the  catheter.  If  called  during  the  first  twenty-four 
hours,  he  may  empty  the  bladder  at  one  sitting  of  three 
quarters  of  an  hour,  but  if  on  the  second  day,  he  should 
draw  off  slowly  only  about  one  third  of  the  contents  of  the 
bladder,  and  after  this  once  every  two  or  three  hours  he 
should  introduce  the  catheter  and  allow  more  urine  to  flow, 
until  in  a  day  or  two  he  finally  empties  the  bladder,  or  he 
may  leave  in  the  catheter  with  its  distal  end  closed  and 
direct  that  six  ounces  be  drawn  off  every  two  hours.  The 
reason  for  these  precautions  is  that  the  too  precipitate 
evacuation  of  an  overdistended  bladder  is  sometimes  fol- 
lowed by  distressing  and  dangerous  effects,  such  as  profuse 
haemorrhage  from  its  mucous  membrane  and  consequent 
general  cystitis,  polyury,  etc. 

The  after-treatment  should  accord  with  the  particular 
necessities  of  the  case.  The  use  of  the  catheter  should  not 
be  abandoned  until  the  patient  is  able  to  empty  sponta- 
neously his  bladder,  which  should  not  again  on  any  account 
be  allowed  to  become  overdistended.  If  the  swelling  of 
the  prostate  does  not  diminish,  the  use  of  the  catheter 
should  be  continued  indefinitely.  In  the  mean  time  the 
urine  should  be  kept  bland  by  the  internal  administration 
of  diluents,  and  the  bladder  should  be  irrigated  once  daily 
with  a  warm  boric-acid  solution,  three  grains  to  the  ounce, 


321 

with  the  addition  of  one  tenth  of  peroxide-of-hydrogen 
sohition. 

By  chronic  retention  of  urine  is  meard  a  gradual  and 
slow  hinderance  to  the  expulsion  of  urine  from  the  bladder. 
Its  characters  are  not  generally  perceived  by  the  patient 
and  are  not  always  manifest  to  the  physician,  pai'tly  because 
this  retention  of  urine  does  not  become  complete  for  many 
weeks  or  months,  or  even  may  never  become  complete. 
When  incomplete  it  is  at  first  characterized  by  much  inita- 
bility  of  the  bladder,  which  is  constantly  wrestling  against 
the  obstruction  to  force  out  the  urine  ;  but  this  subsides  in 
the  course  of  a  few  months,  when  the  sensibility  and  con- 
tractility of  the  bladder  are  somewhat  impaired,  as  evinced 
by  less  painful,  less  urgent,  and  less  frequent  urination,  and 
by  the  stream  being  small,  feeble,  frequently  interrupted, 
and  replaced  by  a  succession  of  drops.  When  the  reten- 
tion is  complete  it  is  characterized  by  inability  on  the  part 
of  the  patient  to  expel  a  single  drop  of  urine. 

As  already  stated,  chronic  retention  of  urine  is  the  out- 
come of  gradual,  progressive,  but  ordinarily  incomplete 
closure  of  the  urethra  or  urethro-vesical  orifice  by  unequal 
enlargement  of  the  prostate  which  obstructs  the  canal. 
From  being  incomplete,  this  retention  of  urine  becomes 
complete  when  the  enlarged  prostate  further  swells  to  the 
extent  of  closing  the  passage.  It  again  becomes  incom- 
plete when  from  overdistention  of  the  bladder  the  urethro- 
vesical  orifice  opens  sufiiciently  to  allow  the  urine  to  over- 
flow and  slobber  out. 

G-rave  errors  are  occasionally  made  in  certain  cases  of 
21 


322 


extreme  distention  of  the  bladder  from  neglect  to  use  the 
catheter  as  a  means  of  diagnosis,  for  in  elderly  men  the 
urine  sometimes  accumulates  so  slowly  and  gradually  that 
the  vesical  distention  causes  little  or  no  pain,  or  the  slight 
pain  is  attributed  to  something  else,  and  increases,  in  the 
course  of  weeks  or  months,  to  such  an  extent  as  to  mislead 
the  unwary.  Such  cases  have  been  confounded  with  as- 
cites, with  abdominal  tumors  connected  with  the  omentum, 
intestines,  liver,  or  kidneys,  with  hydatids,  with  hydrone- 
phrosis, and  even  with  fsecal  impaction.  In  one  instance  a 
trocar  was  plunged  into  the  abdomen,  two  inches  below  the 
umbilicus,  the  physician  believing  the  case  to  be  one  of 
hydatid  cysts,  and  seven  pints  of  fluid  drawn,  which  proved 
to  be  urine. 

Catheters. — To  the  question.  What  is  the  most  suita- 
ble catheter  in  cases  of  retention  of  urine  from  prostatic  ob- 
struction ?  the  reply  is  that  one  catheter  can  not  answer  in 
all  cases.  The  catheter  should,  as  far  as  possible,  be  adapted 
to  a  particular  kind  of  obstruction.  Therefore  the  physician 
should  be  supplied  with  several  very  different  catheters,  and, 
after  due  exploration,  as  before  indicated,  be  able  to  select 
one  w^hich  is  adapted  to  the  particular  deformity  found  in 
the  prostatic  region. 

For  exploration,  the  metallic  instruments  already  de- 
scribed should  be  used,  but  after  this,  and  for  evacuative 
catheterism,  metallic  catheters  should  be  avoided,  for  it  is 
by  their  use  that  false  passages  are  so  commonly  made. 
The  most  dangerous  among  these  is  the  so-called  prostatic 


323 


catheter  of  great  curve  and  extra  length.  The  main  diffi- 
culties in  catheterism,  as  a  general  rule,  are  not  due  to  in- 
creased length  of  the  prostatic  urethra,  but  to  its  several 
deviations ;  and  a  rigid  catheter  of  great  curve,  even  when 
used  with  caution,  ordinarily  fails  to  pass,  besides  being 
very  apt  to  tear  the  urethra. 

The  catheters  which  are  indispensable  in  the  physician's 
armamentarium,  all  but  one — i.  e.,  the  soft,  vulcanized 
India-rubber  "  velvet-eyed  "  catheter — consist  of  a  tubular 
fabric  of  silk,  coated  with  a  pliable  material,  with  a  single 
eye  close  to  the  vesical  extremity  ;  the  form  of  this  extrem- 
ity being  in  accordance  with  the  particular  use  to  which 
each  instrument  is  designed.  The  most  useful  are  the  five 
forms  indicated  below. 

The  catheter  (Fig.  6)  woven  upon  a  curved  stylet  is 
well  adapted  to  cases  of  moderate  supramontanal  (centric) 
enlargement,  or  of  urethro-vesical  bars.  When  greater 
curvature  is  needed,  as  in  a  case  of  very  large  tumor  of 
the  supramontanal  region,  or  when  a  false  route  impedes 
catheterism,  a  stylet  may  be  inserted,  and  the  cathe- 
ter introduced  after  the  method  of  William  Hey.  This 
efficiently  replaces  the  so-called  prostatic  catheter.  All 
the  pliable  catheters  are  from  twelve  to  fourteen  inches  in 
length. 

The  olivary  catheter  (Fig.  V)  is  also  woven  upon  a 
curved  stylet ;  but  the  straight  olivary  catheter,  very  pliable 
for  an  inch  from  the  point  to  the  eye,  is  useful  in  cases  of 
extremely  tortuous  urethrse  from  unequal  enlargement  of 
both  prostatic  lobes. 


824 


The  elbowed  catheter  of  Mercier  (Fig.  4)  is  particularly 
well  adapted  to  cases  of  intra- urethral  tumors,  of  uni- 
lateral   enlargement,   or  of   unequal    enlargement  of    both 


Fig.  4. 


Pig.  5.  Fig.  6.  Fig. 


Fig.  8. 


lobes  of  the  prostate,  but  is  also  successfully  used  in  cases 
of  urethro-vesical  barriers. 

The  crutched  catheter  (Fig.  8),  more  angular  than  the 


325 


elbowed,  answers  well  in  cases  of  great  enlargement  of  the 
supramontanal  region,  the  heel  instead  of  the  point  of  the 
instrument  coming  in  contact  with  and  gliding  over  the  ob- 
stacle. 

The  double  elbowed  catheter  of  Mercier  (Fig.  5)  is 
adapted  to  cases  of  enlargement  of  the  superior  isthmus, 
together  with  supramontanal  increase,  causing  great  depres- 
sion of  the  floor  of  the  prostatic  sinus. 

Respecting  the  size  of  the  catheters,  the  question.  Should 
they  be  small  or  large  ?  is  very  commonly  asked.  The 
answer  is  that  they  should  be  neither  large  nor  small, 
but  adapted  to  the  particular  urethra  to  be  catheterized.  A 
catheter  of  full  size  for  a  urethra  under  the  average  is  too 
small  for  a  urethra  of  extraordinary  large  caliber.  A  No. 
14  (English)  is  small  for  the  latter,  and  entirely  too  large 
for  the  former,  to  which  a  No.  7  (English)  is  likely  to  be 
much  more  suitable.  These,  however,  are  extreme  cases. 
The  most  convenient  size  to  the  physician  and  to  the  pa- 
tient, one  that  strikes  a  fair  average,  is  No.  9  (English).  It 
is  rare  to  find  urethras  that  will  not  admit  a  No.  9,  particu- 
larly in  cases  of  stagnation  of  urine  from  prostatic  obstruc- 
tion, stricture  being  excluded.  Many  patients  who  are 
obliged  to  catheterize  themselves  labor  under  the  delusion 
that  small  catheters  are  safest  and  give  least  pain.  To  the 
use  of  small  catheters  may  be  ascribed  the  majority  of 
prostatic  false  routes  and  the  frequent  attacks  of  urethritis 
and  orchitis  from  which  auto-catheterists  suffer.  The  best 
sized  and  safest  catheter  for  each  individual  is  the  catheter 
that  moderately  fills  and  therefore  does  not   stretch  the 


326 


uretlira.  Sucli  an  instrument  gives  less  pain  than  the  too 
large  or  the  too  small  catheter. 

The  India-rubber  "  velvet-eyed  "  catheter  is  ordinarily 
the  safest  for  general  use  by  the  inexperienced  and  for 
auto-catheterism,  but  its  long- continued  use  upon  or  by  the 
same  patient  is  not  advisable.  The  security  felt  by  the 
patient  is  often  a  source  of  danger,  for  he  is  soon  heedless 
of  the  precautions  advised  by  the  physician  and  suffers 
much  in  consequence.  How  much  more  frequently  the 
physician  is  called  upon  to  remove  from  the  bladder  frag- 
ments of  or  entire  Tndia-rubber  catheters  than  of  other 
firmer  instruments !  But,  aside  from  these  accidents,  the 
urethra  is  often  greatly  irritated  by  the  rubber  catheter,  not 
on  account  of  this  material  itself,  but  of  the  carelessness, 
boldness,  and  undue  frequency  of  its  use,  which  come  of  its 
easy  introduction.  Painstaking,  prudent,  and  intelligent 
patients  soon  acquire  sufficient  skill  in  the  use.  of  any  of 
the  several  pliable  catheters  and  learn  to  keep  them  in  good 
order. 

An  important  advantage  of  the  India-rubber  catheter  is 
that  it  can  be  kept  in  an  aseptic  condition  without  injury 
to  its  structure.  Very  lately  Vergne,  a  Paris  manufacturer, 
announced  that  he  has  succeeded  in  making  pliable  cathe- 
ters vi'hich  are  susceptible  of  being  rendered  aseptic  with- 
uot  injury. 

Puncture  of  the  Bladder. — It  frequently  happens 
that  the  physician  is  called  upon  to  relieve  patients  from 
retention  of  urine  Avhen  ordinary  catheterism  is  impossible 


327 

by  reason  of  false  passages  in  tlie  prostatic  region.  In 
sucli  cases  tlie  common  practice  has  been  to  make  a  supra- 
pubic puncture  with  an  ordinary  trocar  and  insert  a  cathe- 
ter or  a  silver  tube,  to  be  opened  as  often  as  necessary  for 
urination.  Twenty  years  ago  capillary  puncture  with  aspi- 
ration was  introduced  to  the  profession  by  Dieulafoy,  and 
this  novelty  soon  became  the  fashion:  Many  successful 
cases  were  reported,  and  capillary  puncture  with  pneumatic 
aspiration  was  to  be  the  operation  in  retention  of  urine. 
Although  at  first  no  reference  was  made  to  accidents,  in  a 
few  years  the  vogue  of  the  process  was  on  the  wane ;  now 
it  is  employed  with  more  discrimination,  and  only  to  re- 
lieve extreme  distention  once  or  twice,  and  not  ten,  twenty, 
or  thirty  consecutive  times  in  the  same  case.  Capillary 
puncture  with  pneumatic  aspiration  is  an  excellent  resource 
in  medicine  and  surgery;  it  can  not  be  too  highly  praised, 
but  its  abuse  should  be  loudly  decried. 

The  Invaginated  Catheter. — No  kind  of  puncture  of 
the  bladder  ever  can  remove  a  false  route,  and  capillary 
puncture  is  not  so  safe  a  process  as  was  at  first  believed. 
The  consequences  of  the  escape  of  a  few  drops  of  urine  in 
the  prsevesical  connective  tissue  have  been  so  disastrous  in  a 
number  of  cases  as  to  deter  cautious  physicians  from  em- 
ploying this  method  of  relief  except  under  circumstances 
of  the  greatest  urgency ;  but  there  is  an  equally  forcible 
objection  to  its  general  employment^-to  wit,  a  simple,  safe, 
and  efficient  procedure  has  existed  for  the  past  forty  years. 
Why  it  has  not  been  more  frequently  employed  is  not  ap- 


328 


parent,  but  it  is  nevertlieless  valuable.  In  tlie  year  1850 
Dr.  Mercier  published  in  the  Union  medicale  an  account  of 
his  invaginated  catheter  for  use  in  cases  of  prostatic  false 
routes.  Descriptions  and  drawings  of  the  instrument  have 
appeared  in  different  books  and  periodicals,  but  little  heed 
seems  to  have  been  otherwise  taken  of  this  precious  device. 
It  may  be  fairly  stated  that  in  ninety-five  per  cent,  of 
cases  of  prostatic  false  routes  the  invaginated  catheter  can 
be  successfully  applied.  The  instrument  (Fig.  9)  as  now 
made  consists  of  two  catheters — one  metallic,  the  other  non- 


FiG.  9. — Mercier's  inyaginated  catheter. 


metallic.  The  first  or  female  part  is  a  thin-walled  No.  10 
(English)  silver  catheter  eleven  inches  long,  very  slightly 
curved,  and  having  in  its  concavity,  about  half  an  inch  from 
the  point,  an  oval  eye  five  eighths  of  an  inch  in  length  and 
three  sixteenths  in  breadth.  From  the  vesical  extremity  of 
the  eye  is  an  inclined  plane,  which  is  lost  in  the  floor  of  the 
opening  at  the  distance  of  a  quarter  of  an  inch,  serving  to 
tilt  up  the  point  of  the  male  j^art.     This  male  part  is  a  flexi- 


329 


ble  but  linn  "gum"  catlieter  (Xo.  7  English)  eighteen 
inches  long,  fitting  looselr  in  the  lumen  of  the  female  part, 
and  having  a  single  eye  an  eighth  of  an  inch  from  its  point. 
The  way  to  use  the  invaginated  catheter  is  to  introduce  the 
male  into  the  female  part  as  far  as  the  eye  of  the  latter, 
then  to  pass  the  instrument  as  far  as  the  obstacle  and  en- 
gage the  point  of  the  metallic  part  in  the  false  route,  and 
finally  project  the  male  part,  which  will  override  the  false 
route  thus  blocked  and  enter  the  bladder.  If  no  urine 
should  flow,  it  would  be  owing  to  closure  of  the  eye  of  the 
male  part  by  a  blood-clot,  which  might  be  forced  out  by 
the  injection  of  a  little  water  through  the  male  catheter. 
The  female  part  can  then  be  withdrawn  and  the  male  left 
in  as  long  as  may  be  required ;  this  is  the  reason  for  the 
increased  length  of  the  male  part. 

In  twenty  cases  the  author  has  resorted  to  divulsion  of 
the  prostatic  false  route  during  catheterism  with  the  invagi- 
nated catheter.  This  process,  though  comparatively  easy, 
is  not  advisable  except  in  the  most  experienced  hands. 
"While  the  immediate  result  has  generally  been  good,  it  has 
not  been  lasting,  for  he  has  not  known  spontaneous  urina- 
tion to  continue  more  than  two  years  in  any  case  after  this 
operation. 

The  management  of  ordinary  cases  of  chronic  retention 
of  urine  from  prostatic  obstruction,  without  false  routes, 
may  be  summarized  as  follows :  Catheterism  having  been 
successful,  only  a  part  of  the  stagnant  urine  should  be 
drawn  off,  and  the  bladder  not  completely  emptied  for  a 
day  or  two,  and  sometimes  not  for  a  week,  but  the  quantity 


330 


of  retained  urine  should  be  lessened  every  day.  Then  the 
bladder  should  be  daily  washed.  In  many  cases  it  is  not 
wise  to  begin  at  once  with  irrigations,  or  to  use  them  too 
frequently.  Bladders  that  have  long  contained  purulent, 
slimy  urine  do  not  bear  the  contact  of  limpid  fluids  of  low 
specific  gravity  well  at  first.  It  is  therefore  necessary  to 
increase  the  density  of  the  water  used  for  vesical  irrigation 
in  such,  and,  indeed,  in  the  great  majority  of  cases.  A 
good  formula  for  vesical  irrigation  is  the  following,  after 
dilution  of  one  in  twenty  : 

5.  Ilydrarg.  chloridi  corrosivi gr-  v  ; 

Ammonii  chloridi gr.  xx  ; 

Spir.  gaultherias fl  3  ss. ; 

Acidi  borici 3  j ; 

Glycerini fl  3  viij.    M. 

To  half  a  fluidounce  of  this  sohition  are  added  eight 
fluidounces  and  a  half  of  warm  water  (110°  F.)  and  one 
fluidounce  of  peroxide-of-hydrogen  solution. 

These  ten  ounces  of  fluid  are  sufficient  for  four  wash- 
ings of  two  ounces  and  a  half  at  each  sitting.  Only  in  very 
exceptional  cases  should  the  bladder  be  irrigated  more  than 
once  a  day.  After  the  bladder  has  been  completely  emp- 
tied, evacuating  catheterism  should  be  employed  every  five 
or  six  hours,  except  in  cases  of  contracture  with  diminished 
capacity,  when  the  catheter  may  be  needed  every  two  hours. 
In  these  cases  it  is  necessary  to  resort  to  gradual  hydraulic 
dilatation,  a  very  delicate  operation,  which  is  successful 
when  there  has  not  been  too  long  continued  cystitis  with 
connective-tissue  sclerosis. 


331 


The  general  treatment  in  cases  of  stagnation  of  urine 
should  be  conducted  in  accordance  with  sound  hygienic 
pi'inciples  and  little  else.  Opium,  belladonna,  or  hyoscya- 
mus  should  be  used  only  to  relieve  extreme  pain  and  spasm. 
The  urine  should  be  kept  bland  by  the  use  of  diluent  bev- 
erages and  the  rectum  completely  emptied  every  day,  for, 
next  to  stagnant  urine  in  the  bladder,  the  accumulation  of 
faeces  in  the  rectum  is  the  greatest  source  of  discomfort. 
A  little  generous  wine  at  dinner,  and  a  drink  of  brandy  or 
whisky  and  water  at  bed-time,  may  be  allowed  without  fear 
of  causing  local  irritation ;  it  is  only  in  excess  that  alcoho 
is  hurtful  in  these  as  in  all  circumstances. 

Elderly  men,  and  even  young  men,  suffering  from  vesi- 
cal disease  are  prone  to  constipation,  and  this  too  often  re- 
mains undiscovered  until  the  patient's  life  is  imperiled 
by  the  local  mischief  arising  from  impacted  faeces  in  the 
colon  and  rectum,  or  by  the  baneful  effect  of  stercoral 
intoxication.  Due  appreciation  of  these  evils  naturally 
leads  to  an  early  inquiry  directed  to  the  state  of  the 
function  of  defecation.  A  common  reply  of  the  patient  to 
this  inquiry  is  that  his  bowels  are  regular,  and  yet  a  little 
cross- questioning  reveals  the  fact  that  he  has  had  no  alvine 
evacuation  perhaps  for  three  or  four  days,  or  that  the  ftecal 
discharges  have  been  scanty  and  hard  for  several  weeks. 
Therefore  a  cathartic,  or  an  enema  with  a  liberal  amount  of 
ox-gall  or  of  glycerin,  should  be  prescribed  in  any  case 
where  there  may  even  be  the  slightest  doubt,  and  in  nearly 
all  cases  the  frequent  use  of  aperient  medicines  is  indi- 
cated.    A  surgeon  of  large  experience,  who  flourished  in 


332 


this  city  during  the  second  quarter  of  the  present  century, 
when  called  to  minister  to  cases  of  retention  of  urine  the 
nature  of  which  seemed  doubtful,  was  in  the  habit  of  say- 
ing to  his  assistants :  "  Order  a  copious  enema  and  wait." 
It  often  happened  that  nothing  more  was  needed,  the  enema 
having  removed  the  impacted  faecal  mass  which  had  been 
the  cause  of  the  urinary  retention. 


The  question  of  prostatotomt  and  prostatectomy, 
internal  and  external,  will  not  now  be  discussed,  but  a  few- 
words  will  be  said  of  circumstances  under  which  a  portion 
of  the  prostate  may  be  excised  during  suprapubic  cystotomy 
for  a  tumor  or  stone.     When  epicystotomv    has    become 


Fig.  10.— The  author's  intravesical  prostatectome. 


necessary  for  the  extraction  of  a  stone  or  the  ablation  of  a 
morbid  growth,  it  may  be  proper  to  excise  a  portion  of  the 
prostate  or  a  pedunculated  prostatic  tumor  projecting  in 
the  bladder  and  interferino-  with  urination.     Pedunculated 


333 


tumors  can  be  excised  by  means  of  scissors  witli  rectangu- 
lar blades;  but  if  a  bar  or  median  cutgio"wtli  is  to  be  cut 
the  rectangular  intravesical,  suprapubic  prostatectome  (Fig. 
10),  constructed  on  the  principle  of  the  hawk-bill  scissors 
of  Dr.  Skene,  will  be  found  to  answer  the  purpose  of  excis- 
ing as  considerable  a  portion  of  the  prostatic  obstruction  as 
may  be  desired,  leaving  a  A"-shaped  chink  for  the  escape  of 
urine,  or,  with  a  later  instrument,  a  U-shaped  chink. 

The  removal  of  a  urethro-vesical  tumor  of  the  prostate 
during  suprapubic  lithotomy  was  done  about  half  a  century 
ago  by  Amussat. 


INDEX. 


Abnormal  urine,  21,  60. 

chemical  properties  of,  63. 

physical  characters  of,  59. 

tints  of,  61. 
Abscess,  82. 

perinephric,  95. 

periprostatic,  162. 

peri-urethral,  250. 

prostatic,  162. 
Accidents  of  urethritis,  239. 
Aconuresis,  57. 
Acute  prostatitis,  159. 

diagnosis  of,  161. 

progress  of,  161. 

symptoms  of,  160. 

treatment  of,  163. 
Acute  retention  of  urine,  317. 

diagnosis  of,  318. 

management  of,  319. 

mechanism  of,  318. 
Adenitis,  249. 

bulbo-urethral,  184,  253. 

inguinal,  249. 
Adenomata,  37. 

ectocoeliac — entocoeliac,  38. 
Algeinuresis,  56. 
AUoti-ylic  affections,  43. 
Alterations  in   the  urinary  secre- 
tion, 19. 
Angeioneoplasmata,  37. 
Arsura,  192. 

Arteries  of  the  urinary  apparatus, 
12. 


Ascheturesis,  53. 
Auxesis,  31. 

Balanitis,  243. 
Balano-posthitis,  245. 

treatment  of,  245. 
Bladder,  121. 

abscess  in  the  walls  of  the,  123. 

"  catarrh  "  of  the,  102. 

"  catarrhal "  fluxion  of  the,  102. 

columnar,  123. 

contracture   of    the,    110,    135 
152. 

dilatation  of  the,  119,  152. 

divei'ticula  of  the,  124. 

gangrene  of  the,  1 26. 

normal  appearances  of  the,  121. 

perforation  of  the,  123. 

sacculation  of  the,  124. 

stenosis  of  the,  30. 

ulceration  of  the,  123. 
Blastomata,  39. 

syphililic — syphiloid  —  tubercu- 
lous, 39. 
Blennorrhagia,  190. 
Bulbo-urethral  adenitis,  184,  253. 

diagnosis  of,  186. 

symptoms  of,  185. 

progress  of,  186. 

treatment  of,  187. 
Bulbo-urethral  glands,  181. 

anatomy  of  the,  182. 

histology  of  the,  182. 


336 


Bulbo  urethral  glands,  history  of 
the,  181. 
physiology  of  the,  183. 

Cancer,  34. 
"Catarrh,"  102,  191. 

of  the  bladder,  102. 

venereal,  191. 
Catheter,  invaginated,  154,  327. 
Catheterism,  1. 

dangers  of,  162. 

Hey's  method  of,  154,  323. 

in  acute  prostatitis,  163. 
Catheters,  322. 

crutched,  324. 

curved,  323. 

elbowed,  324. 

double-elbowed,  325. 

India-rubber,  323. 

of  bronze  from  Pompeii,  3. 

size  of,  325. 
Chancre — infecting  and  non-infect- 
ing, 195. 
Chancroid,  195. 
Chemical  properties   of  abnormal 

urine,  59. 
Chronic  cystitis,  105. 

from   urethral    stricture,   treat- 
ment of,  149. 

from      prostatic       obstruction, 
treatment  of,  150. 
Chronic  phlegmasia,  2*7. 
Chronic  prostatitis,  170. 

causes  of,  170. 

diagnosis  of,  174. 

physical  chai-acters  of,  172. 

symptoms  of,  172. 

treatment  of,  176. 
Chronic  retention  of  urine,  321. 

diagnosis  of,  322. 


management  of,  329. 
Chronic  urethritis,  290. 
causes  of,  296. 
diagnosis  of,  300. 
nature  of,  291. 
physical  characters  of,  298. 
treatment  of,  302. 
Circumcision,  193,  246. 
Clap,  190,  193. 

Colic,  spei-matic,  273,  278,  281. 
Complications  of  urethritis,  243. 
Composition  of  the  urinary  appa- 
ratus, 8. 
Concretions,  33. 
in  the  prostate,  173. 
in  the  seminal  vesicles,  268,  278. 
in   the   spermatic    canals,    265, 
278. 
Conjunctivitis,  virulent,  240. 
Consequences  of  urethritis,  248. 
Contracture  of   the  bladder,  110, 
135,  152. 
gradual  hydraulic  dilatation  for 
the  cure  of,  138. 
Cryptitis,  253. 
Cystitis,  102. 

anatomical  characters  of,  123. 
calculous,  148. 
causes  of,  102. 

cystotomy  for  the  cure  of,  146. 
diagnosis  of,  126. 
from  deviations  in  quantity  or 
quality  of  the  urinary  secre- 
tion, 103. 
from   extension    of    phlegmasic 
action  of  neighboring  organs, 
108. 
from  injuries  of  the  bladder  and 
from     other    local    irritants, 
108. 


837 


from  stagnation  and  fermenta- 
tion of  urine  due  to  obstructed 
urination,  110. 
interstitial,  myxo,  peri,  102. 
nature  of,  102. 
nitrate  of  silver  for  the  cure  of, 

142. 
prognosis  of,  130. 
progress  of,  115. 
symptoms  of,  111. 
treatment  of,  132. 
Cystohsemorrhagia,  120. 
management  of,  156. 
Cystopylometer,  316. 
Cystotomy,  146. 

infrapubic  and  suprapubic,  for 

the  cure  of  cystitis,  146. 
lithoclastic,  3. 
Cysts,  4i. 

degeneration,    endothelial,    epi- 
thelial, parasitic,  teratic,  41. 
of  the  prostate,  172. 

Dactylius  aculeatus,  42. 
Delayed  urination,  55. 
Diagnosis,  65. 

of  acute  interstitial  nephritis,  81. 

of  acute  prostatitis,  161. 

of  chronic  prostatitis,  174. 

of  cystitis,  126. 

of  diseases  of  the  urinary  appa- 
ratus in  general,  65. 

of  perinephritis,  97. 

of  pyelonephritis,  85. 

of  urethritis,  219. 
Didymitis,  257. 

acute  parenchymatous,  258. 

subacute  parenchymatous,  257. 

superacute  parenchymatous,  258. 

treatment  of,  260. 


Difficult  urination,  54. 
DifPuse  prostatitis,  159. 
Diplosoma  crenatum,  42. 
Disordered  urination,  52. 
Disorders,  functional,  45. 
Distoma  hajmatobium,  42. 
Diurnal  incontinence  of  urine,  57. 
Dysuresis,  54. 

EcHiNOCOccus  hominis,  42. 
Echmasis,  31. 
Ectasis,  32. 

of  the  bladder,  119,  124,  152. 

of  the  seminal  vesicles,  272,  279. 

of  the  spermatic  canals,  272,  280. 
Ejaculatory  ducts,  267. 

dilatation  of,  271. 

obstruction  of,  271,  278. 

occlusion  of,  279. 
Emulgent  aiteries,  12. 
Endothelial  neoplasmata,  35. 
Enlargement  of  the  prostate,  310. 

catheterism  in,  323. 

diagnosis  of,  313. 

different  forms  of,  311. 

early  manifestations  of,  312. 

nature    of    the    alterations    of 
structure  in,  311. 
Entozoic  parasites,  42. 
Epididymitis,  254. 

peritonitis  caused  by,  255. 

treatment  of,  259. 
Epithelial  neoplasmata,  34. 
Erratic  worms,  42. 

Fever,  urethral,  11. 
Filaria  sanguinis,  42. 
Foreign  bodies,  43. 

as  causes  of  cystitis,  109. 
s  causes  of  urethritis,  213. 


338 


Frequency  of  diseases  of  the  uri- 
nary apparatus,  6. 

Frequent  urination,  52. 

Function  of  the  urinary  apparatus, 
]8. 

Functional  disorders  of  the  uri- 
nary apparatus,  45. 

General  pathology  of  the  urinary 

apparatus,  22. 
General  therapeutics  of  the  urinary 

apparatus,  Q'J. 
Glycosuria,  1. 

as  a  cause  of  cystitis,  63,  106. 
Gonecystitis,  263. 

acute,  271. 

chronic,  2*78. 

diagnosis  of,  2*74,  279. 

symptoms  of,  273,  278. 

treatment  of,  275,  281. 
Gonococcus,  206. 
"  Gonorrhoea,"  190. 
"  Gonorrhoea!  ophthalmia,"  240. 
"  Gonorrhoea!  rheumatism,"  28f>. 
Granular  urethritis,  291. 

H^MATANGEIOMA,  37. 

cavernous,  cirsoid,  37. 
HtBmaturia,  49. 

arising  from  the  too  precipitate 
evacuation   of  the  distended 
bladder,  120,  156. 
Haemorrhage,  120. 

urethral,  239. 

vesical,  120. 

management  of,  156. 
Hydronephrosis,  32. 
Hyperlithuria,  7,  21. 

as  a  cause  of  cystitis,  106,  117. 

as  a  cause  of  urethritis,  209. 


Identism,  the  doctrine  of,  194. 
Identists,  194. 
Impossible  urination,  57. 
Incontinence  of  urine,  57,  310. 

diurnal  and  nocturnal,  57. 

in  elderly  men,  57,  310. 
Infibulation  of  the  prepuce,  244. 
Inguinal  adenitis,  249. 
Innervation  of  the  urinary  appara- 
tus, 9. 
Inoma,  36. 

circumscribed  and  difPuse,  36. 
Interstitial  prostatitis,  159. 
Invaginated  catheter,  328. 

utility  of,  in  cases  of  prostatic 
false  routes,  329. 
Involuntary  urination,  57. 
Irrepressible  urination,  53. 
Ischuria,  57. 

Larvae  of  flies  in  the  bladder,  42. 
Leiomyoma,  37. 
Leucocytes,  25. 

emigration  of,  25. 

conversion  of,  into  pus  and  into 
scar  tissue,  26. 
Leucomaines,  43. 
Lithoclastic  cystotomy,  3. 
Lithotomy,  3. 

infrapubic,  3. 

suprapubic,  4,  333. 
Lithotripsy,  its  invention,  5. 
Lymphadenoma,  38. 
Lymphangeiitis,  248. 
Lymphatic  vessels  of  the  urinary 

organs,  16. 

Malformations,  44,  47. 
Monsters,  44. 

nature  and  classification  of. 


339 


Myoma,  37. 

circumscribed,  diffuse,  oV. 
Myoneoplasmata,  37. 
Myosarcoma,  37. 
Myxadenoma,  38. 

Neoplasmata,  33. 

augeio,  epithelial,  endothelial, 
myo,  33,  37. 

Nephradenoma,  38. 

N"ephritis,  74. 

ascending,  amicrobic,  descend- 
ing, diffuse,  interstitial,  mi- 
crobic,  75,  79. 

Nocturnal  incontinence  of  urine, 
57. 

Non-identists,  194. 

Nutrition  of  the  urinary  apparatus, 
12. 

Obstruction, 

prostatic,  311. 

urethral,  311. 

urethro-vesical,  309. 
Oliguria,  19,  59. 

Ophthalmia,  "  gonorrhoeal,"  240. 
Orchidectomy,  2. 
Orchitis,  254. 

Painful  urination,  56. 
Paraphimosis,  247. 

modes  of  reduction  of,  248. 
Parasites,  entozoic,  42. 
Parenchymatous  prostatitis,  159. 
Pathology,  general,  of  the  urinar} 

apparatus,  22. 
Pentastoma  denticulatum,  42. 
Perinephric  abscess,  95. 
Perinephritis,  87. 

diagnosis  of,  97. 


gangrene  a  rare  termination  of, 

94. 
lumbar  fistula  from,  95. 
nature  of,  89. 
progress  of,  93. 
symptoms  of,  91. 
treatment  of,  98. 
Periprostatic  abscess,  162. 
Peri-urethral  abscess,  260. 
Phimosis,  245. 
Phlegmasia,  24. 

nature,  processes,  and  stages  of, 
24,  29. 
Poisons,  43. 

inorganic,  leucomainic,  ptomain- 
ic,  43. 
Polyuria,  7,  59. 

following  the  precipitate  evacu- 
ation of  the  distended  blad- 
der, 120. 
from  extensive  burns,  105. 
Posthectomy,  1,  246. 
Posthetomy,  245. 
Posthitis,  243. 

Prepuce,  infibulation  of,  244. 
Prognosis,  65. 
of  acute  interstitial  nephritis, 

81. 
of  diseases  of  the  urinary  appa- 
ratus, 65. 
of  pyelonephritis,  85. 
Prophylaxis   of    diseases    of    the 

urinary  apparatus,  66. 
Prostate,  311. 
abscess  of,  162. 
unequal  enlargement  of,  311. 
i  Prostatectomy  and   prostatotomy, 
332. 
Prostatic  obstruction,  312. 
Prostatitis,  159,  254. 


340 


Prostatitis,  acute,  159. 

causes  of,  159. 

diagnosis  of,  !61. 

diffuse,  159. 

from    exposure    to   damp  cold, 
167. 

interstitial,  159. 

parenchymatous,  159. 

progress  of,  161. 

symptoms  of,  160. 

treatment  of,  163. 

chronic,  1*70. 

causes  of,  l*?**. 

diagnosis  of,  174. 
.  physical  characters  of,  172. 

symptoms  of,  171. 

treatment  of,  176. 
Prostato-eystitis,  176. 
Prostatoliths,  33,  173. 
Prostatorrhoga,  170. 
Ptomaines,  43. 

Puncture  of  the  bladder,  326. 
Pyelitis  and  nephritis,  281. 
Pyelonephritis,  79. 

amicrobic,  79. 

microbic,  83. 

diagnosis  and  treatment  of,  84, 
86. 
Pyonephrosis,  32. 
Pyorrhoea,  192. 

Pyosapraemia  as  a  consequence  of 
urethritis,  283. 

Rectangular  sound,  315. 

in  prostatic  exploration,  315. 

in  vesical  exploration,  315. 
Regions  of  the  urethra,  9. 
Retention  of  urine,  57. 

in  elderly  men,  309. 

acute  and  chronic,  316-321. 


causes  of,  311. 

diagnosis  of,  313. 

management  of,  319. 
Rhabdomyoma,  37. 
Rheumatism,  "gonorrhoeal,"  285. 

Sarcoma,  35. 
Seminal  vesicles,  264. 

anatomy  of,  265. 

calcareous  infiltration  of,  280. 

ectasia  of,  272,  279. 

phlegmasia  of,  270. 

physiology  of,  268. 

sympexia  in,  269,  278. 
Septicaemia  as    a   consequence  of 

urethritis,  282. 
Slimy  urine,  124,  151. 
Slow  urination,  55. 
Sound,  rectangular,  315. 
Spermatic  canals,  265. 

calcareous  infiltration  of,  280. 

ectasia  of,  272,  280. 

occlusion  of,  271,  272,  280. 

phlegmasia  of,  280. 

sympexia  in,  265,  278. 
Spermatic  colic,  273,  278,  281. 
Spiroptera  hominis,  42. 
Spurious  worms,  42. 
Stenosis,  30. 

of  the  bladder,  30. 

of  the   urethra,   30,    221,   224, 
239. 
Stricture  of  the  urethra,  221,  224, 

239. 
Strongilus  glgas,  42. 
Sychnuresis,  52. 
Sympexia,  33. 

in  the  prostate,  173. 

in   the   seminal    vesicles,    269, 
278. 


3il 


ill  the    spermatic    canals,  265, 
278. 
Syphilis  and  chancroid,  39,  192. 

Teratic  affections  of  the  urinary 
apparatus,  43. 

Therapeutics,  general,  of  the  urin- 
ary apparatus,  6*7. 

Trachelocystitis,     107,    114,    117, 
127,  281. 
treatment  of,  147. 

Traumatic  affections  of  the  urin- 
ary apparatus,  43. 

Trichina  spiralis,  42. 

Tuberculosis,  nature  of,  40. 

Urethra,  stricture  of  the,  221,  224, 
239. 

the  six  regions  of  the,  9. 

veins  of  the,  15. 
Urethral  cryptitis,  253. 

fever,  11. 

haemorrhage,  239. 

phlegmasia,  192. 

stenosis,  221,  224,  239. 
Urethritis,  189. 

abortive  treatment  of,  224. 

accidents  of,  239. 

acute,  220. 

antiquity  of,  193. 

astringent  injections  in,  225. 

benign,  219. 

causes  of,  200. 

chancroidal,  202,  222. 

chronic,  221,  290. 

complications  of,  243. 

consequences  of,  248. 

contagium  of,  204. 

copaiba  and  cubebs  in,    25. 

diagnosis  of,  219. 

general  treatment  of,  227. 


gonococci  in,  206.    ■ 

granular,   hygienic    precautions 
in,  226. 

infecting,  200,  222. 

local  treatment  of,  227. 

mediate  contagion  of,  207. 

nature  of,  194. 

non-contagious,  208,  222. 

rational  treatment  of,  226. 

subacute,  220. 

superacute,  221. 

tubercular,  308. 

virulent,  202. 
Urethro-vesical  obstruction,  3 1 2. 
Urinary  apparatus,  7. 

composition  of  the,  8. 

frequency  of  diseases  of  the,  6. 

function  of  the,  18. 

general  pathology  of  the,  22. 

innervation  of  the,  9. 

nutrition  of  the,  12. 
Urination,  52.' 

delayed,  55. 

difficult,  54,  56. 

frequent,  52. 

impossible,  57. 

involuntary,  57,  310. 

irrepressible,  53. 

painful,  56. 

slow,  55. 
Urine,  18. 

abnormal,  63. 

diurnal    and    nocturnal    incon- 
tinence of,  57,  310. 

influence  of  seasonal  variations 
on  the  secretion  of,  19. 

proportion   of    excreta    to   the 
aqueous  element  of  the,  18. 

quantity  and  quality  of  urine  ex- 
creted, 18. 


342 


Urine,  retention  of,  in  elderly  men, 
309. 

slimy,  124,  151,  312. 

tints  of  the,  61. 
Uroliths,  33. 

Veins  of  the  urinary  organs,  13, 15 
Venereal  catarrh,  191. 
Vesical  haemorrhage,  120. 
management  of,  156. 


Vesicles,  seminal,  264. 

anatomy  of  the,  265. 

calcareous  infiltration  of,  280. 

ectasia  of  the,  272,  279. 

physiology  of  the,  268. 

phlegmasia  of  the,  271. 

sympexia  in  the,  269,  278. 
Virulent  conjunctivitis,  240. 

Worms,  erratic  and  spurious,  42. 


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